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COPYRIGHT DEPOSIT. 



LECTURES 



ON 



Orthopedic Surgery 



JOHN RIDLON, A.B. (Chicago), A.M. (Tufts), 
M.D. (Columbia), 

Professor of Orthopedic Surgery in the Northwestern University Medical Schools ; 

Senior Orthopedic Surgeon St. Luke's and Michael Keese 

Hospitals, and the Home for Destitute 

Crippled Children, Chicago, 



AND 

ROBERT JONES, F.R.C.S.E., 

Honorary Surgeon to the Royal Southern Hospital, Liverpool, England. 



PHILADELPHIA : 

Edward Stern & Co., Inc. 
1899. 



A 



^s 






LIBRARY of CONGRESS 

TvwCoiHes Received 

JAN 10 1906 

Copyileht Entry 

"GtASS XXc. Wftr 

7 7 1 3 X 

COPY B. 



Copyright secured by John Ridlon, 1899. 



M 



L 



5^ 



THIS WORK 

IS DEDICATED WITH INFINITE LOVE AND RESPECT 
TO THE MEMORY OF 

HUGH OWEN THOMAS 



BY THE AUTHORS 



PREFACE. 



THE authors of this volume have undertaken to 
preserve the things of most value in the writings 
on orthopedic surgery by the late Hugh Owen Thomas, 
modified by their own personal experience and convic- 
tions ; they have endeavored to make a volume for the 
use of the student and the general practitioner and have 
omitted much that would be of interest and inserted 
much that may not be of interest to the orthopedic 
specialist. These lectures have been delivered by Dr. 
Ridlon in the Northwestern University Medical Schools, 
and many of them have been added to and amended 
by Mr. Jones. Some of the lectures, however, have 
not been read by Mr. Jones, and he should not be 
held responsible for any Americanisms that appear in 
these pages. 

When the publication of these lectures was com- 
menced in the Philadelphia Medical Journal it was 
intended to cover the entire subject of orthopedic sur- 
gery and make a complete book, but the change in 
management and in type of the journal led to a discon- 
tinuance of the project, and the incomplete work is now 
offered with many misgivings and apologies. 

John Ridlon. 



TABLE OF CONTENTS. 

Preface v 

GE^^ERAL Principles Relating to Chronic Joint Disease . . 3 

Spondylitis 16 

Sacro-Iliac Disease 110 

Hip Disease 120 

Knee-Joint Disease 185 

Ankle Disease and Tarsal Disease 211 

Great Toe Disease 218 

Shoulder Disease 221 

Elbow Disease .... 238 

Wrist Disease 243 

Carpal, Metacarpal and Phalangeal Disease 248 

Rachitic Deformities 249 

Club-Foot 292 

Congenital Dislocation of the Hip 331 

Congenital Dislocation of the Shoulder 343 

Congenital Dislocation of the Patella 351 

Congenital Constriction Bands 351 



GENERAL PRINCIPLES RELATING TO CHRONIC 
JOINT-DISEASE. 

Chronic joint-disease is the term generally used to 
indicate a chronic pathologic process affecting any of 
the structures of a joint, which, untreated, may be ex- 
pected to result in permanent disability or in deformity. 
The structure first involved is usually the bone ; next 
in order of frequency is the synovial membrane ; but 
the source whence the pathologic condition arises gen- 
erally determines the first structure to be involved. 

The pathologic process in chronic joint-disease is 
usually a primary tubercular inflammation, or a second- 
ary tubercular inflammation transmitted from some 
primary focus located elsewhere, such as a cheesy 
bronchial lymph-node, or it may be a tubercular 
inflammation engrafted upon a local traumatic or 
syphilitic inflammation. It is possible that tuberculosis 
may become engrafted upon a rheumatic inflammation, 
but from clinical experience this appears to be doubtful. 

A tubercular inflammation is the reaction which 
accompanies local tubercular infection. It is charac- 
terized by the growth and development of miliary 
tubercles. Its progress is usually slow ; after reaching 
a certain stage it is usually slowly retrogressive. 

A traumatic inflammation of a joint is the reaction 
which takes place after an injury, such as a sprain, a 
fracture into a joint, or a dislocation. The tendency in 
healthy individuals always is toward recovery ; and in 
severe injuries, such as dislocations, the temporary 
disability is so great that perfect resolution of the 
inflammation takes place during the period of enforced 

3 



rest. This also happens in cases in which fractures extend 
into joints, unless an over-anxious or meddlesome sur- 
geon delays the resolution of the inflammation by fre- 
quent manipulations of the part, as in the use of passive 
motion. 

Passive motion was at one time generally employed 
when fracture occurred near or extended into a joint, 
in the belief that it was necessary to prevent stiffness 
of the joint. We are, however, very positively of the 
opinion that nothing is gained by early passive motion, 
but, on the other hand, that forced flexions and exten- 
sions of a joint, while the inflammatory reaction, evi- 
denced by tenderness and muscular spasm, remains, 
not infrequently result in a continuance of the inflam- 
mation, and ultimately in tuberculosis of the joint. 

Inherited syphilis plays an important role in the 
etiology of chronic joint-disease. Just what the rela- 
tions are between inherited syphilis and tuberculosis 
we do not know. From clinical observation, however, 
it would appear that the disease may begin as a syphi- 
litic focus and ultimately become infected with tubercle- 
bacilli; and any focus located at an epiphyseal line 
may fairly be suspected of being, or of having been, 
syphilitic. Even when it cannot be demonstrated 
that syphilis itself has been inherited, the consti- 
tutional defect which is often found in the children of 
syphilitics renders them fit subjects for tubercular 
infection. 

Tubercular joint-disease begins in either the bone or 
the synovial membrane ; there is no evidence to show 
that it ever begins in the ligaments or in the cartilage. 
Tuberculosis of the bone in the neighborhood of a joint 
almost invariably begins as a primary or a secondary 
focus. 

A primary focus in the bone is believed to arise in 
the following manner : A few tubercle-bacilli carried in 



the blood-current gather together at some point where 
the blood-current becomes sluggish, or where there is 
actual stasis, somewhat after the manner that sticks 
and leaves gather in an eddy at the side of the current 
in a stream ; here the bacilli colonize, and a gray miliary 
tubercle results; from this other tubercles develop, and 
the focus grows. Usually the development is uniform 
on all sides, and a globular focus results, but occasion- 
ally it is more or less elongated. 

A secondary focus in the bone is believed to result 
from the occlusion of a terminal artery by a cheesy 
particle coming from some previously existing tuber- 
cular lesion. This previously existing tubercular lesion 
has more often than otherwise been found to be in the 
bronchial lymph-nodes, although occasionally the oldest 
lesions are found in the abdominal lymphatics. When 
the bronchial lymphatics are involved it is believed that 
the infection found entrance by way of the lungs, and 
by way of the digestive tract when the abdominal 
lymphatics are the parts first diseased. When a ter- 
minal artery in the end of a bone becomes occluded by 
a tubercular particle, the area supplied by the occluded 
vessel becomes a fertile field for the growth of the 
tubercle bacillus, and the progress of the disease is from 
the infecting particle in this direction. As a result, a 
cone-shaped focus is ultimately found, with its base 
resting against the cartilage of the joint and its apex at 
the point where the artery was plugged. This is also 
called a triangular focus, from its triangular surface on 
vertical section, and it is also called an infarction focus. 

The development of the focus, except as to its shape, 
is the same in either the primary or the secondary form. 
The surface of the section of a focus is grayish-red, yel- 
lowish-white, or yellow, the boundary being somewhat 
reddened by collateral hyperemia. In the very early 
stage the transparent gray tubercles may, with the aid 



of a lens, be seen throughout the spot ; later on they will 
only be found at the periphery, the central part having 
already become cheesy. This caseation appears to result 
from the extending occlusion of the blood vessels by the 
pressure of the growing tubercles. Thus death first 
appears in the center of the mass, and, as the growth 
advances at the surface, the central area of necrobiosis 
also increases, and is still found to be surrounded by a 
gray, or grayish-violet, membrane, easily separable from 
the surrounding tissues. In this outer membrane bacilli 
may be found in abundance, while in the cheesy mass 
filling the cavity they can rarely be demonstrated by 
microscopic examination or by cultivation; neverthe- 
less, inoculation of a rabbit's cornea with this central 
cheesy material invariably gives rise to tubercle, forcing 
us to the conclusion that spores exist therein. 

As a rule, the caseating process extends, and con- 
tinues to undergo liquefaction centrally, until it reaches 
the surface of the bone, where it finds exit through the 
periosteum, or through the cartilage and synovial mem- 
brane into the joint. Occasionally drying or dehy- 
dration takes place, and the spot may even calcify and 
remain unchanged for years, the surrounding hypere- 
mia leading to exudation of round cells and the forma- 
tion of a fibrous capsule, or to sclerosis of the bone. In 
other cases resolution may take place before the cheesy 
stage has been reached; or cicatricial healing may result 
after suppuration or caseation by the development and 
encroachment of healthy granulation-tissue ; sequestra 
of very considerable size may disappear, and only the 
scar remain, after the manner of an ordinary infarct in 
the spleen or the kidney. 

Tuberculosis of the synovial membrane is known to 
occur as secondary to adjacent bone-tuberculosis ; and 
it is also believed to occur primarily by infection from 
the blood. 



Primary synovial infection is believed to occur in all 
cases when the synovial disease has a traumatic etio- 
logical factor; but it is also seen clinically when there 
is no history of traumatism and no history of an osseous 
lesion. In these cases the older and yellow tubercles 
are found on the surface of the membrane, and the more 
recent gray tubercles deeper within the substance of 
the membrane. 

Secondary synovial infection may result, as already 
stated, from the rupture of a liquefied osseous focus, 
through the cartilage and synovial membrane. Under 
such circumstances, the older yellow tubercles are found 
on the surface of the membrane, and the more recent 
gray tubercles deeper within its substance. 

A local secondary infection of the synovial membrane 
may also result from the extension of the osseous focus 
without the rupture of the liquefied cheesy mass. Then 
the older tubercles are found deeply imbedded, and the 
more recent ones are at or near the surface. 

A third and more rare form of joint-tuberculosis is 
believed to commence as a primary synovial tubercu- 
losis and to proceed rapidly to destruction of the en- 
tire articular cartilage and infiltration of the exposed 
spongy^ portion of the bone ; it may make its way 
through the entire diaphysis and into the medullary 
cylinder itself. 

The liquefied cheesy focus is called a tubercular ab- 
scess. When it breaks through the periosteum, it spreads 
beneath the soft parts, and in the case of superficial 
joints may soon be made out by palpation. When it 
ruptures into a joint the disease may go on to the rup- 
ture of the synovial sac or not. If the synovial sac 
eventually ruptures we have the same condition of af- 
fairs as exists when a tubercular abscess has made its 
way through the periosteum. 

The tubercular abscess, when it has escaped from the 



8 

bone or from the joint, develops comparatively slowly. 
Many months may elapse before it finds its way to the 
surface ; it follows the direction of least resistance, in- 
fluenced by gravity; the size of the abscess bears no 
direct relation to the bony focus ; an abscess containing 
one or two quarts may have had its start from a bone- 
focus the size of a pea, and the bone-focus may have 
healed long before the abscess finds its way to the sur- 
face. These abscesses present neither heat, redness 
(except when about to break), tenderness, nor pain. 

The fluid contents appear differently at different 
stages. Early it is thick, creamy, and yellow; but it 
lacks the greenish color and viscidity of phlegmonous 
pus. Later on we find minute yellow or yellowish- 
white flocculi floating in a thinner turbid fluid ; and 
still later curds or clots of fibrin and shreds of con- 
nective tissue are found floating in a more or less clear, 
whey-colored liquid. The tubercular pus contained in 
these abscesses presents no microorganisms on staining 
or cultivation, but inoculation of the pus in fit subjects 
results in the development of tuberculosis. 

The walls of these abscesses are made up of grayish- 
yellow or violet membrane (the old " pyogenic mem- 
brane ") of greater or less thickness, always easily de- 
tachable, consisting of a soft brittle tissue composed 
essentially of closely aggregated miliary tubercles im- 
bedded in fibrin, the cavity itself being lined with this 
material. The sinuses formed by the spontaneous 
opening of these abscesses, and those which form after 
incision, are lined with the same membrane, its thick- 
ness appearing to depend very much upon the amount 
and duration of the irritation to which the abscess- 
cavities and sinuses have been subjected. 

The predisposing causes of tubercular joint-disease 
are not limited solely to the local conditions, and to 
inherited syphilis and to traumatism, already men- 



tioiied. Congenital tuberculosis cannot be denied, 
although undoubtedly the condition is a rare one. On 
the other hand a constitutional predisposition is, as a 
rule, handed down from the tuberculous parent to the 
child ; and the same constitutional predisposition is at 
times found in several of the children of a family hav- 
ing non-tuberculous parents and grandparents. Tu- 
berculosis of the joints may occur after the infectious 
diseases of childhood, such as measles, whooping-cough, 
and scarlet fever, and after exhausting diseases, 
parturition, privation, and prolonged dissipation; but 
the best conditions of nutrition offer no certain pro- 
tection against its occurrence. 

The general symptoms of tubercular joint-disease, 
speaking broadly, fall into one or the other of three 
classes : 

1. Primary synovial disease of non-traumatic origin. 

2. Bone-disease either from primary infection or 
secondary to disease in other tissues, associated or not 
with traumatism. 

3. A purely traumatic lesion, such as a sprain, which, 
in the course of time, has become chronic from lack of 
treatment. 

The joint of the first class presents, at least for a time, 
only a distended joint-capsule, the normal bony out- 
lines being indistinct or completely lost, with true or 
false fluctuation on palpation. There is to the touch no 
local elevation of temperature, no limitation of motion 
except the mechanical limitation due to the thickened 
and distended capsule, no muscular atrophy, no limp- 
ing except after prolonged use, no complaint of pain, 
and usually no tenderness. 

The joint of the second class presents no distended 
capsule, the bony outlines being normal; there often 
is a local elevation of temperature, and a tender point 
can be made out when a superficial joint is involved ; 



10 

limping begins early, and is a constant symptom when 
a joint of the lower extremities is involved, and dis- 
ability is present when a joint of the upper extremities 
or the spine is affected, although intermissions in these 
symptoms are occasionally met with ; muscular shrink- 
ing and more or less restriction of joint-motion are 
always found ; pain comes on, after a time, in most 
cases, but may be absent throughout the entire course 
of the disease. 

The" joint of the third class is characterized by the 
symptoms peculiar to traumatism. Usually it is a 
sprain, for rarely does a fracture into a joint, or a dis- 
location, result in chronic disease. There is swelling 
and infiltration of the soft parts about the joint, with 
either true or false fluctuation ; increased heat can 
always be felt ; local pain of an aching character is 
almost invariably present ; muscular atrophy and 
restriction of motion are always found; and, finally, 
there is a general tenderness to pressure rather than a 
small and sharply defined tender point. 

As the disease progresses in either class, the three 
pictures above shown merge into one another to form 
a composite, presenting all the symptoms above enu- 
merated. In addition, there is deformity varying with 
the location of the disease. If the spine is affected, 
there is a posterior angle or curvature, with the opening 
or concavity to the front, and early in the disease there 
is a lateral bending in many cases ; if the hip, it is 
flexed and usually abducted or adducted ; if the knee, 
it is flexed, and later on the leg is abducted and rotated 
outward; if the ankle, there is plantar flexion; if the 
shoulder, there is adduction ; and if the elbow or wrist, 
there is flexion. 

Complications : Abscesses appear in nearly half of 
all cases, and partial or. complete subluxation at the 
hip and knee occurs in a few cases. Lardaceous dis- 



11 

ease of the liver and kidneys and meningeal tuber- 
culosis are the fatal complications. 

The 2>rognosis in tubercular joint-disease must be 
considered as to life, as to the duration of the disease, 
and as to the ultimate functional result. 

As to life : From 8% to 33% die as the result of the 
tubercular disease, the variation depending upon the 
part involved, the age of the patient, the constitutional 
predisposition, and upon the general hygienic sur- 
roundings and the orthopedic treatment available. 

As to the duration of the disease and the ultimate 
functional result : In general, other things being equal, 
the younger the patient the shorter will be the duration 
and the better will be the ultimate functional result. 
Smaller joints recover more quickly and more perfectly 
than larger ones. A certain number of joints recover 
either under mechanical treatment or under operative 
treatment, or without any treatment whatever, with 
limbs in fair position and joints possessed of a good 
range of motion ; and suppuration, whether treated or 
untreated, is no bar to this result. On the other hand, 
certain cases, no matter how early treatment be com- 
menced, or how carefully carried out, will go on to 
recovery with short limbs, or stiff joints, or ultimately 
to death. The duration of disease in individual joints 
or particular patients cannot be accurately foretold. 
Relapses rarely occur if the surgeon recognizes the 
signs of perfect recovery. The cases that relapse after 
mechanical treatment or operative treatment are those 
in which treatment has been suspended before the 
articulation has regained perfect soundness. 

The treatment of tubercular joint-disease may be 
divided into hygienic, medicinal, mechanical, and opera- 
tive. In the hygienic treatment sunshine, pure air, 
bathing, and an abundance of proper food are of chief 
importance, and the value of digestible fats should 



12 

never be lost sight of. Voluntary physical exercise 
is not essential to good health, as some have assumed ; 
as a rule, exercise cannot be indulged in without seri- 
ous risk to the diseased joint in the early treatment of 
very many cases. The medicinal treatment, both gen- 
eral and local, is far from satisfactory. It has not been 
demonstrated that any medicine has a direct remedial 
action. General tonics may be indicated from time to 
time, but obviously cannot be continued without inter- 
mission throughout the months and years that these 
patients must remain under treatment. So long as the 
appetite and digestion remain reasonably good we are 
accustomed to give little or no medicine, except cod-liver 
oil, unless there be a reasonable suspicion of inherited 
syphilis. Thehistory of syphilis in the parents can rarely 
be elicited. One may, however, be warranted in suspect- 
ing syphilis in the following cases : All cases of chronic 
joint-disease in children under three years of age, 
except when there is a positive history of advanced 
tuberculosis in the mother at the time the child was 
born ; in all patients suffering from multiple joint-dis- 
ease ; in colored children, and in the children of other 
classes that are notoriously syphilitic. In such cases 
we are accustomed to give mercury and potassium 
iodid in full doses. When the bichlorid or biniodid in 
solution is not well borne, we are accustomed to give 
the officinal powder of mercury with chalk, or an in- 
unction of blue ointment may be used. The dose, in 
any instance, may be as large as would be given to an 
adult. Potassium iodid may be given in increasing 
doses, from gr. v to 5 iij t. i. d. 

Local external medication, such as liniments, salves, 
tincture of iodin, blisters, and the cautery, in strictly 
tuberculous joints, is absolutely useless and at times 
harmful. Deep injections into the joints, into the 
tubercular foci, and into the neighborhood of the dis- 



13 

eased tissues are too painful to be tolerated by children, 
and too uncertain in their results for routine treatment. 
Iodoform suspended in oil or glycerin has attained a 
certain popularity among surgeons having neither skill 
nor experience in the use of orthopedic appliances ; but 
there is little evidence to show that the treatment pos- 
sesses any curative value, while there is abudant evi- 
dence showing that in the vast majority of cases it is 
positively harmful. 

Local congestion of the joint and its immediate 
neighborhood, which has recently come into use in 
Germany, is, in some cases, of positive advantage. This 
method of increasing the nutrition locally was first rec- 
ommended by the late Dr. Hugh Owen Thomas and 
employed by him for many years. The recent "dis- 
coverer" appears to be wholly ignorant of Thomas' 
writings. 

The mechanical treatment of chronic joint-disease 
aims to protect the diseased joint from injury inflicted 
by movement at the joint, from shocks during locomo- 
tion, from the burden of weight-bearing when the joints 
of the spine or lower extremities are involved, and 
from the intra-articular pressure due to the involuntary 
muscular spasm in Nature's attempts at immobiliza- 
tion. 

The first and most important problem is the immo- 
bilization of the joint. The materials used are of little 
importance, provided the essential principles are not 
lost sight of; namely, to immobilize a joint it is neces- 
sary to put at rest the muscles governing motion at 
that joint, and to do this the immobilizing apparatus 
must extend to the limits of these muscular attach- 
ments ; to perfectly protect a joint from the shocks of 
locomotion and weight-bearing, recumbency must be 
employed; and to counteract intra-articular pressure 
resulting from muscular spasm, the irritation inducing 



14 

the spasm must be allayed. This can be accomplished 
more often than otherwise by immobilization of the 
joint, but in some instances traction upon the limb is 
of very material assistance. In a few instances traction 
aggravates the pain and muscular spasm, and in the 
vast majority of cases its sedative action is only as an 
aid to other forms of immobilization. In the treatment 
of these joints it may be laid down as a law that wdiat- 
ever most quickly relieves pain and tenderness will 
most quickly relax the muscular spasm and place the 
joint in a condition favorable to recovery. 

The essential of any orthopedic appliance is that the 
framework be firm, unyielding, and free from tremor; 
that the padding be sufficient to protect the soft parts 
from harmful pressure, nor yet so soft nor so thick as to 
diminish the effectiveness of the rigid frame ; and that 
the covering be such as will not readily become infected 
with septic microorganisms. 

The operative treatment includes aspiration and in- 
cision of abscesses, erasion and excision of joints, and 
amputation of limbs. 

Abscesses should never be subjected to operative in- 
terference unless the patient be suffering from septic 
infection, or the bulk of the abscess prevents effective 
mechanical support. When from either of these indica- 
tions it becomes necessary to operate upon a tubercular 
abscess it should be freely incised, its contents evacuated, 
its lining membrane rubbed off with a piece of sterile 
gauze, its bone-focus, if such be found, curetted, the 
whole cavity washed out and dried, and the wound 
through the healthy tissues accurately closed through- 
out its entire extent with numerous sutures. Drainage, 
and especially drainage by a rubber tube, should not 
be used. If all or most of the tubercular tissue has 
been removed, and the operation has been aseptic, pri- 
mary healing will result; otherwise the abscess will 



15 

refill and demand a second opening, or open spontan- 
eously, usually through some part of the closed incision. 
If the wound be still aseptic artificial drainage need 
not be used ; if it be septic it may be washed out and 
drained. Prolonged drainage, however, always results 
in a sinus, w^th greatly thickened tubercular walls, 
and which heals only after a very prolonged period. 

Erasion consists in opening the joint or bone focus 
and scraping out the diseased tissue. When the syno- 
vial membrane is not involved, and the disease is 
wholly confined to a bone-focus, erasion is a justifiable 
procedure, provided the focus can be accurately located. 
When, however, the synovial membrane is involved, 
either with or without the presence of a neighboring 
bony focus, the operation of erasion has not proved 
satisfactory and is now rarely performed. 

Excision of a joint consists in the sawing off and 
removal of one or both bones going to make up the 
joint, and the consequent total removal of all diseased 
tissues in very many cases. The operation can be very 
readily done at the knee and elbow, and at these joints 
it succeeds in the majority of cases in eradicating the 
disease; but at the other joints the results are far less 
satisfactory. At the hip it is practically impossible to 
excise the acetabulum and remove all of the disease, 
and relapses are of frequent occurrence. Among ortho- 
pedic surgeons excisions are rarely performed except as 
a life-saving measure, or as a time-saving measure in 
adult cases when poverty renders prolonged mechanical 
treatment impossible. Excision should never be prac- 
tised in children except as a life-saving measure ; for in 
children an excision results in an arrest of growth in 
the limb, sometimes amounting to six or eight inches 
in cases of excision at the knee. 

Amputation is performed only as a life-saving mea- 
sure. In children it is often preferable to excision. 



16 



SPONDYLITIS. 



SjDondylitis is an inflammation of one or more of 
the bones of the spine, characterized by stiffness and 
disability, and sooner or later resulting in a greater or 
less degree of spinal deformity. 

The synonyms in common use are Pott's disease, 
spinal caries, hump-back, and hunch-back. 




Fig. 1. — Caries of lower dorsal spine, showing complete destruction of one 
of the vertebral bodies. (Krause.) 



17 




Fig. 2. — Foci of disease starting in anterior surface'of vertebral bodies, and 
separated by one bealthy vertebra. (Krause.) 

The causes are tuberculosis by infection (common) 
or by inheritance (rare), inherited syphib's, and injury 
from falls, blows, and the lifting of heavy weights. 
The disease also follows and appears to depend upon 
scarlatina, measles, whooping-cough, and other infec- 
tious diseases ; but however it begins, or whatever be 



18 

its specific origin, the symptoms presenting and the 
indications for treatment are practically almost identi- 
cal, and all cases sooner or later show the presence of 
the tubercle-bacillus. 

The pathology practically amounts to the deposit of 
tuberculous material and the subsequent growth and 
development of the focus, usually in the anterior part 
of the body of one or the bodies of several verte- 
brae; very rarely do the symptoms indicate that the 
tuberculosis commences in the intervertebral discs, or 
in the lamina, articular facets, or processes. As the 
disease develops the spine often presents a bowing or 
curvature due to involuntary spasm of the muscles in 
their attempt to immobilize the diseased area. Later 
on, when a considerable portion of a vertebral body has 
been softened by the tubercular growth, the bone crushes 
together and a posterior angle is formed. At times the 
entire body of a vertebra will disai)pear, a very acute 
angle being the result. At other times there will be 
only a small spot of decay in several vertebrjie, when in 
place of the angular deformity the spine becomes curved 
posteriorly. In rare instances a well-marked destruc- 
tive process takes place in two parts of the spine sepa- 
rated by several healthy vertebrae, in which case two 
angular deformities result. Late in the disease, when 
healing has progressed to a considerable extent, two or 
more vertebral bodies may be found consolidated into 
a confused mass by the deposit of new bone. 

The symptoms of spondylitis may be common to the 
disease in any part of the spine whatsoever or peculiar 
to the part of the spine affected. The symptoms com- 
mon to the disease in any part of the spine are as 
follows : The face expresses apprehension, pain, and 
premature old age. The patient walks and moves with 
care, as if to avoid any jar or sudden movement. There 
can be obtained a history of uneasiness, fretting, and 



19 



irritability, and for soroe tinie the patient has been dis- 
inclined to exercise as actively as usual and has been 
easily fatigued. Distant pain, felt in the terminal fila- 
ments of the nerves whose motor branches go to supply 
the muscles controlling motion of the spine at the point 
of disease, has generally been felt, though it may have 




Fig. 3. — Bony deposit and ankylosis in a 
(Krause.) 



case of healed spondylitis. 



20 

been absent, as may also have been restlessness, crying 
and screaming during the first hours of sleep. De- 
formity may or may not have been noticed, and the 
complications — abscess and paralysis — may or may not 
have appeared. 

For proper examination the patient should be stripped 
naked. Girls who have reached the aged of puberty 
and women should receive certain consideration, and it 
is customary to examine such with the back alone bared. 
It may be convenient to have the undershirt put on in 
front as an apron with the sleeves pinned or tied about 
the neck; the skirts can then be dropped to the level 
of the greater trochanters and held with a large safety- 
pin, or by a piece of bandage tied around the hips. 
The back is then inspected for any deviation, excurva- 
tion, incurvation, or prominent vertebrae. If found, the 
-disease may be suspected of being present at the middle 
of the curvature; but it must be remembered that 
spondylitis easily demonstrated is usually present some 
months before deformity of the spinal column is appa- 
rent. All of the normal motions should now be tested, 
both actively and passively ; the head should be rotated 
to right and to left, and the shoulders twisted in the 
same directions while the pelvis is firmly held ; and the 
spine should be bent forward and backward, and to the 
right and to the left. Any portion which shows rigidity 
to all the normal motions is, or has been, the seat of an 
inflammatory process ; but if there be rigidity to bend- 
ing in one direction only, or if bending in any one 
direction be normally free, the diagnosis of spondylitis 
is rendered extremely doubtful. It is upon this rigidity, 
which for a long time is due solely to involuntary mus- 
cular spasm, that the diagnosis must depend ; it is ever 
present, both waking and sleeping, and nothing abolishes 
it except profound anesthesia, or the termination of 
the inflammatory process. It is the first symptom to 



21 



appear and the last to disappear ; and when, and only 
when it is no longer present, can. a cure be safely 
predicated. 

Tenderness to direct pressure over the suspected area. 




Fig. 4.— Paiued facial expression, often seen in patients suffering from 
spondylitis. 

unless local abscess be present, will not be found. This 
local tender point, which is taught by the professor of 
and text-book on general surgery as the most important 
diagnostic symptom, always counts against rather than 



22 

in favor of the diagnosis of spondylitis. It should be 
remembered that the disease is located in the vertebral 
bodies, and usually in- their anterior parts, and in any 
case is far beyond the reach of direct pressure ; and 
consequently tenderness to direct pressure, unless sup- 
ported by strong confirmatory evidence, is to be looked 
upon as indicative of some other condition than the 
disease in question. 




Fig. 5. — Rigid lumbar spiue in commeuciug spondylitis before Ihe appear- 
ance;of angular deformity. 

Downward pressure and concussion upon the head, 
and sudden twisting of the spine by wrenching at the 
shoulders w^hen the patient is off his guard, are tests 
as unnecessary as harmful. They will not be found to 
be of any value in the very early period and can 
scarcely fail to inflict injury as well as pain when the 
disease is at all well advanced. 



23 

Sooner or later deformity of the spine appears, and 
a lateral curvature, with or without twisting of the ver- 
tebn\? — rotation — often appears before kyphosis, the 
so-called ''angular curvature," makes its appearance, 
[f but one, two, or three vertebrae be affected, and if the 




Fi(i. C— Lateral deformity preceding angular deformity in commencing 
spondylitis. 

destructive process has been considerable, the deformity 
fairly approximates an angle ; but if several vertebrae 
are diseased each to only a slight degree, the deformity 
will be a curve. 



24 

Motor paraplegia, affecting both lower extremities 
and at times the bladder and rectum, and at times also 
the upper extremities, may come on before the bony 
deformity, or with the bony deformity, or comparatively 
late in the disease. It is generally due to thickening 





Fig. 7. — Commencing angular deformity of spondvlitis. 



25 

of the membranes of the cord, from the contiguity of 
the inllammation in the bone, occasionally to an 
actual invasion by the tubercular inflammation. Para- 
plegia occurs by far the most frequently when the 
disease is located in the upper dorsal region. It bears 




J/ 



'^^^''*^^'!^S 



Fiij. 6. — iJuibu-lumbar spondylitis witli shoulders shifted to the right. 

no relation toHhe acuteness of the angle ; it may disap- 
pear while the bony deformity goes on increasing, and 
it has seldom been shown to depend upon bony 
pressure. The paraplegia is characterized by an exag- 
geration of all the tendon-reflexes in the affected 



26 

extremities, a tonic spasm of all the muscles, and an 
inability, more or less complete, to move any portion 
of the affected parts. The nerves of sensation are very 
rarely involved. 

Although tubercular " pus '' is probably formed to 
some extent in all cases, the tubercular abscess does 
not appear in more than half the cases. Abscesses are 
quite frequently seen when the disease is in that part 
of the spine which lies below the diaphragm; less 
frequently when disease is in the cervical region; and 
still less frequently when the disease is in the dorsal 
spine above the diaphragm. The abscess may make 
its way in any direction, opening externally, or into any 
of the open or closed cavities of the body, or it may be 
absorbed even after it has attained very considerable 
proportions. 

Symptoms of Cervical Spondylitis. — The first symptom 
is restriction of the normal range of motion; followed 
after a time by malposition and a greater degree of 
stiffness. The malposition of the head depends upon 
the location of the disease. More often than otherwise 
the upper two or three vertebrse are diseased, and the 
head is twisted and bent forward and to one side into 
the position of wry-neck ; one or both sterno-mastoid 
muscles are rigidly prominent, and often the posterior 
muscles as well. When the disease is lower, the chin 
is advanced and dropped towards the chest and an 
angular projection of the spine at the point of disease 
may be felt ; when the disease is still lower, the chin is 
elevated and relatively somewhat advanced, and the 
head is thrown backward towards the shoulders, which 
are raised to meet it. At times the posterior muscles 
are so much contracted that they simulate an abscess. 
The face expresses apprehension and the head is moved, 
if the patient can move it at all, with anxious care. 
Pain may be complained of running up the back of the 



27 

neck and head, down the arms, or in the chest. In 
early cases the deformity, and in fact all of the symp- 
toms, are considerably relieved by even a short period 
of recumbency. 




Fig. 9.— An old case of tubercular spondylitis, with posterior, lateral and 
rotary deformity. 



28 

For the proper examination of a case of suspected 
cervical spondylitis, the patient should be stripped to 
the waist. The attitude and the range of active motion 
should be noted; the range of passive motion should 
be tested, and the neck should be palpated for kyphosis 
and for a Huctuatino; swellinir. If the ranue of motion 




Fig. 10.— The same case showu in Fig. y stooping forward, viewed from the 
rear, showing by the parallel lines, a and b, the degree ol lateral deviation ; 
showing also the amount of rotary deformity. 

be restricted in all directions to some degree, the diag- 
nosis of spondylitis may be considered as certam. In 
very young children who become frightened at the 
approach of a stranger the range of motion of the head 
may be tested by placing the patient across the parent's 
knees; in the prone position the head will not be let 



29 

dangle, no matter how prolonged the examination, and 
in the supine position he will not carry it forward as in 
the first act of rising. 

The complications of cervical spondylitis are abscess 
and paraplegia. Abscess does not occur very frequently ; 




Fig, 11.— Cervical spondylitis, with twisted head and contracted and prom- 
inent stern o-mastoid muscles. 



30 




Fig. 12. — Cervical spondylitis ; head bent to one side and resting on the 
raised shoulder. 

when it does occur it usually points laterally back of 
the sterno-mastoid muscle ; it may point in the pharynx. 
The pharynx, however, need not be examined unless 
some symptom points to abscess in that location. Be- 
fore the formation of abscess the finger in the throat 




Fig. 1?..— Cervical spondylitis; head thrown forward, with chin approaching 
chest. 



31 

will reveal nothing; it is very disgusting to the patient, 
and the normal prominence of the vertebral bodies may 
mislead the surgeon. Paraplegia is seldom met with. 
When present it may affect both upper and lower ex- 
tremities, or the lower only. A more complete descrip- 
tion of the paraplegic symptoms will be given in connec- 
tion with dorsal spondylitis, of which paraplegia is 
more often a complication. 

Symptoms of Dorsal Spondylitis. — Before the appear- 
ance of kyphosis the diagnosis must depend upon per- 




FiG. 14. — Cervical spondylitis; 
frotQ abscess. 



head thrown back ; sinus in side of neck 



sistent distant pain, often treated for many months as 
gastric pains ; upon a disinclination to indulge in rough 
play ; a growing tendency to stand with the elbows 
resting on a chair or table ; a grunting respiration, and 
upon an inability to rise from a stooping posture, or pick 
up an object from the floor without resting the hand 
upon some piece of furniture or climbing hand over 
hand upon his own legs. 

Any distant pain which does not readily yield to 
proper medication should lead to a careful examination 



32 

of the spine. Often there is crying when the child is 
lifted, and a cough accompanying a grunting respiration. 
If the upper two or three dorsal vertebrae be the ones 
involved, the head may be thrown backward and the 
neck held rigid to forward or lateral bending, and para- 
plegia may even come on before any kyphosis can be 
made out. When the disease arises in the lower dorsal 
region, the patient may limp and complain of pain in 
the thigh, as in hijxlisease, and this before any deform- 
ity is noted. Lateral deviation of the column, with or 




Fig. 15. — Cervical spondylitis. Patient will not let head dangle. 

without rotation of the vertebrae, is often present before 
the anteroposterior deformity appears. 

In patients too young and timid to submit patiently 
to an examination by the surgeon it is convenient to 
let them lie prone across the parent's separated knees ; 
if there is disease, the spine will not sag into an anterior 
curve in the normal way. If placed sitting upon a table 
with the knees straight, the child will not bend forward 
arching the spine in the usual way. A spine which is 



33 

held rigid in some extent to bending in all directions 
must be seriously suspected of being diseased. 

^yhen kyphosis has appeared, however, the diagnosis 
will be readily made, for, in addition to the peculiar and 
striking deformity, all the symptoms heretofore men- 
tioned are likely to be found on careful investigation. 
Sooner or later projection forward of the chest takes 
place, compensatory and proportionate to the angular 
deformitv of the back. 




Fig. 16. — Cervical spondylitis. 1 atieut will uot lei liead dangle. 

Paraplegia, which is more common when disease is 
in the upper dorsal spine than elsewhere, may come on 
early, before any deformity has appeared, or at any time 
during the course of the affection or during its latest 
stages, and, having disappeared, may recur again and 
again. It begins with exaggeration of the tendon-re- 
flexes, stumbling in walking, increasing lack of muscu- 



34 

lar control, and goes on until all control over the lower 
extremities is lost and the limbs are held rigidly ex- 
tended ; at times they are drawn up with spasmodic 
crampings, and may suddenly, without the patient's 



Fig. 17. — Dorsal spondylitis. Great shortening of tlie trunk; lower angles 
of scapulse nearly down to the iliac crests. 

volition, be extended with a jerk. Sudden passive dor- 
sal flexion at the ankle-joint induces marked ankle- 
clonus. On rare occasions the sensory nerves, and at 
the same time the bladder and rectum, are aff'ected. 



35 



Abscess does not frequently appear when the disease 
is above the diaphragm, although it is probable that col- 
lections of tubercular debris form to some extent in all 
cases. When the abscess does find its way to the sur- 
face, it usually makes its appearance from between the 
ribs at a distance of from one to four inches from the 
line of the spinous processes; rarely, however, it makes 
its way downward before appearing at the surface. In 




Fig. 18. — Projecting chest accompanying and compensatory to upper dorsal 
spondylitis. 

disease in the lower dorsal vertebrae the abscess usually 
travels downward in the posterior mediastinum under 
the ligamentum arcuatum internum of the diaphragm 
into the sheath of the psoas muscle and thence follows 
its course into the groin. 

Simulating abscess a bursa may form directly over 
the angular kyphosis in a case subjected to the pressure 



^36 

of a corset or ^a corset-brace. We have seen two such 
cases ; in one case the fluctuating tumor was two inches 
in diameter and in the other three inches. Both tumors 
were located symmetrically over the most prominent 
portion of the spine, extending equally to each side of 




Fig. 19.— Dorsal spondylitis, with abscess below right scapulae. 

the line of the spinous processes. We have not met 
with a tubercular abscess similarly located. 

Symptoms of Lumbar Spondylitis. — The first symptom 
recognized is usually an awkward gait, a limp, or a 
slight lordosis. The shoulders are thrown backward, 
one foot is slightly advanced, and the patient walks 



37 



with care and holds his spine rigid. He is even less 
inclined than in dorsal disease to forward bending. If 
there be pain, it is usually felt down the anterior and 
inner surfaces of the thigh. Most of the symptoms 
enumerated as characterictic of disease in the dorsal 




Fig. 20. — Dorsal spondylitis, with sinus from 



in left loin. 



region will be found present. Contraction of one or 
both psoas-muscles may come on before the formation 
of abscess and before the appearance of kyphosis. It 
is this early involuntary spasm of the psoas-muscle, 



38 

flexing the thigh and limiting its extension, before the 
appearance of deformity that leads to the mistaken diag- 
nosis of hip-disease, even by experienced observers. 

To test for contraction of the psoas-muscle the patient 
is placed prone upon the table, the pelvis is held firmly 




Fig. 21. — The long posterior curvature of dry caries. 



down with one hand, while with the^other hand, first 
one and then the other knee is lifted upwards. The 
freedom with which they can be raised and the differ- 
ence in extent of movement or the extent to which each 



39 

of them differs from the normal must be noted. The 
rigidity of the spine is tested by placing one hand upon 
the back at about the tenth dorsal vertebra, while with 
the other hand both of the lower extremities are lifted 
at once, carrying the hips with them ; in this way not 




Fig. 22.— Dorso-lumbar spondylitis, with protuberant abdomen. 

only backward bending but also lateral bending can be 
tested. It is upon this rigidity that the diagnosis must 
depend. In healthy children the spine can be bent 
backward so far that the thighs are at nearly a right 
angle with the upper dorsal spine. 



40 

Paraplegia is not common, owing no doubt to the fact 
that below the first lumbar vertebra the dura mater only 
accommodates nerves. The cauda equina does not oc- 
cupy so great a space as the cord itself along with the 
nerves leaving it in the higher regions of the spine. 




Fig. 23. — Testing for psoas contraction. 



When paraplegia occurs, it differs in no way from the 
same condition when found complicating dorsal disease. 
Abscess is frequent, usually following the course of 
the psoas muscle and pointing on the anterior surface 
of the thigh below Poupart's ligament, and opposite the 
insertion of the muscle. When the disease is below 



41 

the third lumbar vertebra the abscess may pass down 
and point in the buttock; this is due to the entrance of 
the pus into the psoas-sheath where it is continuous 
with the sacral end of the pelvic fascia, and which 
passes down to the pyriformis, and leaves the pelvis 
through the great sacro-sciatic foramen ; or with disease 
in any of the lumbar vertebrae, the pus may pass later- 
ally, following the nerves, and point in the loin some 
inches from the spine. 




Fig. 24.— Lumbar spondylitis. Patient climbing up his legs after reaching 
to the ground. 



Differential Diagnosis. — A strain may give rise to the 
early symptoms of spondylitis ; for a sprain left un- 
treated in a tuberculous subject may become a true 
tubercular spondylitis. A strain carries its distinct his- 
tory of injury, and often presents a local tender point ; 
the pain on motion is relatively greater and the invol- 
untary rigidity relatively less than is found in spondy- 



42 



litis ; in a case of sprain there is no angular deformity 
and rarely any rounded curvature ; there is no distant 
pain, no abscess, and no paraplegia. 

Torticollis is closely simulated at first glance by 




Fig. 25. — Upper lumbar spondylitis with psoas abscess presenting on tlie 
thigh in the usual location. 



spondylitis in the upper cervical region, and yet, in 
many cases, the diagnosis can be made at sight. In 
wry-neck, the chin points away from the prominent 
sterno-mastoid muscle ; in spondylitis, it points towards 



43 

that muscle, if only one muscle be prominent. In 
spondylitis, the movements of the head are restricted 
in all directions ; in torticollis, only in one direction — 
that direction which puts the shortened muscle on the 
stretch. 




Fig. 26. — Upper lumbar spondylitis with abscess pointing in the groin 
above Poupart's ligament. 

A rachitic spine closely resembles the " rounded cur- 
vature" of spondylitis. The deformity is not infre- 
quently a rigid one, but the rigidity has a more elastic 
feel than that of a tubercular spine; bilateral psoas- 



44 



contraction is occasionally present. The condition is 
found only in young children, and is usually associated 
with other manifestations of rickets. There is no dis- 
tinct pain, no abscess, and no spastic motor paralysis. 
The mistaking of a rachitic spine for spondylitis will, 
however, be of little harm to the patient, since the 
rachitic spine demands a rigid support. 




Fig. 27. — Dorso-lumbar spondylitis, infected lumbar abscess with sloughing 
sinus, enlarged liver and kidneys, and great emaciation. 



Scoliosis — rotary lateral curvature — will not be mis- 
taken for spondylitis, as the curvature is not usually 
rigid until some time has elapsed and the deformity has 
become considerable. On the other hand, spondylitis 
may be mistaken for lateral curvature, and the neces- 
sary immobilization withheld and possibly exercise ad- 
vised. A slight lateral curve, with or without rotation, 



45 

if it be rigid, is probably a commencing spondylitis ; 
exercises should be withheld and a support applied ; a 
few months' observation will clear up the diagnosis. 
While pain is rarely associated with scoliosis, it is the 
rule in spondylitis, though it should not be forgotten 
that it may be absent in both. 

The hyperesthetic spine, also called the irritable 
spine and the hj^sterical spine, if patiently and,^ care- 




FiG. 28.— Front view ol patient shown in Fig. 27. 



fully examined, gives no rigidity from involuntary 
muscular spasm. The spine is held more or less rigid 
to bending in one direction, or to bending in more than 
one direction ; but the characteristic rigidity of invol- 
untary muscular spasm is wanting, and the patient 
usually complains of pain on voluntary bending, a 
symptom very rarely found in spondylitis. There is 



46 



no distant pain, the pain being confined to some por- 
tion of the spine itself and associated with tenderness 




Fig. 29.— a case of tubercular spondylitis simulating scoliosis, showing 
lateral and rotary deformity. The onset was very rapid and the rigidity great. 
The diagnosis was not made until treatment by exercises had increased the 
deformity and rigidity . The deformity was gradually corrected under treat- 
ment by immobilization. 



47 

on pressure. The condition is most frequently found 
in young women, often associated with other hysterical 
manifestations, and may remain unchanged for years. 
There is no true kyphosis. 

Malignant disease of the spine in its very early stage 
cannot be diagnosticated from commencing spondylitis. 
The history of the case as to hereditary tendency, taken 
together with the age of the patient and his general ap- 
pearance, may make the diagnosis of malignant disease 
probable, but nothing can be positively said until the 
progress of the disease, or the symptoms due to pressure 
of the tumor clear up the doubt. The symptoms in 
malignant disease grow steadily worse despite all treat- 
ment, while in tubercular spondylitis, treatment by 
immobilization and recumbency invariably brings relief 
to a very considerable extent. 

The typhoid spine can, of course, be found only as a 
sequel of typhoid fever. The typhoid spine presents 
tenderness on pressure, and on lateral and forward 
bending. There is no true kyphosis, no special pain 
in the nerve-distribution, and no psoas-contraction ; 
the onset is sudden, and the recovery rapid. 

Hip-disease is not infrequently the diagnosis when 
contraction of the psoas muscle comes on in lumbar 
spondylitis prior to kyphosis. The patient walks with 
a limp, complains of pain in the groin or along the 
anterior surface of the thigh, the thigh is flexed on the 
pelvis, and attempts to overcome flexion are resisted by 
involuntary muscular spasm, and give the patient pain. 
It will be found, however, that the thigh can be flexed 
to the normal degree, and that when flexed sufficiently 
to fully relax the psoas-muscle, rotation at the hip-joint 
is free, painless, and normal. In a word, in lumbar 
spondylitis extension, and possibly inward rotation 
during full extension, are the only motions at the hip- 
joint that are restricted by muscular spasm, whereas in 



48 



hip- disease motion is restricted in all directions. It is 

upon this difference in the restriction to motion at the 

hip-joint that hip-disease is excluded from the diagnosis. 

Sacro-iliac disease is not of frequent occurrence, and 




Fig. 30.— Front view of patient shown in Fig. 29. 



49 

its early symptoms are obscure. It rarely occurs in 
young children, except in association with disease at 
the sacro-lumbar junction. When the sacro-iliac joint 
alone is involved, the lumbar spine will be held rigid on 
forward bending, but gentle, passive bending backwards 
and laterally will generally be found to be free. In 
all suspected cases examination should be made by 
way of the rectum, since swelling appears earlier within 
the pelvis than upon the surface external to the joint. 

The prognosis of spondylitis must be considered as 
to deformity and function, as to duration, as to life, and 
as to the complications. 

As to deformity and function: In the cervical and 
dorso-lumbar regions, under favorable opportunities as 
to treatment, the deformity may be reduced, and often 
entirely eradicated, if consolidation has not already 
taken place, and increase in the deformity may be pre- 
vented even if consolidation has commenced. In the 
upper dorsal region, from the first to the sixth vertebra, 
the deformity may be expected to increase under any 
form of treatment which does not include prolonged and 
uninterrupted recumbency as its essential feature. From 
the sixth to the tenth dorsal vertebra an increase can 
generally be prevented, but rarely can the deformity be 
reduced except by forced straightening under an anes- 
thetic. When the disease affects the lower lumbar 
region, the fourth and fifth vertebrse and sacrum, the 
deformity may be expected to come on, and to increase 
up to a certain point, unless the patient be treated con- 
tinuously in the recumbent posture until consolidation 
is well advanced. In a word, if the spine can be made 
straight and kept so sufficiently long for the ossific 
matter to deposit in the space made vacant by the dis- 
ease, an ankylosis, free from deformity, or nearly so, 
will result. In a few cases, more or less, restoration of 
the normal motion is gained. The lack of early diag- 



50 



nosis and of early, energetic and prolonged treatment, 
may be considered as the cause of the deformity which 
ultimately results in so many cases. 

As to duration : It must not be expected that any 




Fig. 31.— Upper dorsal spondylitis with marked lateral and rotary deform- 
ity. The development of the deformity was comparatively rapid ; it was very 
rigid ; and horizontal traction hy weight-and-pully, in bed for a year, very 
greatly reduced the deformity, diminished the rigidity and confirmed the 
diagnosis. 



51 

case, even the one presenting only the few symptoms 
requisite for a certain diagnosis and most favorably 
circumstanced as to nursing and treatment, will recover 
within a year ; two years constitute a short time, and 
the average case will require treatment for from three 
to four years, and many a much longer time. 

As to life : Although spondylitis is a most prolonged 
and serious disease, the prognosis as to life is remark- 
ably good. In neglected cases the death-rate may run 
as high as 30%; in cases receiving proper nursing and 
conservative treatment the death-rate is not more than 




Fig. 32.— Cervical spondylitis simulatiug wry-neck. The chin points towards 
the prominent sterno-mastoid muscle. In wry-neck the chin points away from 
the prominent sterno-mastoid muscle. 

8%; to this may be added 10% for such cases as are 
subjected to operative measures. 

As to the complications : Abscesses are reabsorbed 
in about half the cases, provided the spine is properly 
protected. Abscesses that open spontaneously and are 
left to empty without interference heal as kindly as 
sinuses resulting from incision, and rarely afflict the 
patient with symptoms of septic poisoning. Abscesses 
that are incised rarely heal by first intention, and as 
a rule become septic and continue to discharge as long 



52 

and often longer than those left without interference. 
The duration of an abscess arising from tubercular 
spondylitis covers months and often years. 





' w- /^ 




Fi&. 33.— A hyperesthetie spine, with lateral deviation, simulating com- 
mencing dorsal spondylitis. 



Paraplegia, being due in nearly all cases to pressure 
upon the cord from the inflammatory products in the 
neighborhood of the bony tuberculosis, may be ex- 
pected to pass off as the actiA^e inflammation subsides ; 
all such cases recover from the paralysis, if the patient 
be kept recumbent sufficiently long. A few cases die 
from an invasion of the cord itself by the tubercular 
inflammation and a few from a displaced bon}^ seques- 
trum so placed as to press upon the cord. In all cases 
in which the sensory nerves and the bladder and rectum 
are involved a fatal issue may be anticipated. The 
average duration of the paraplegia in cases subjected 
to conservative treatment is somewhat more than thirty 
weeks ; but the authors have observed a complete res- 
toration of function to the paraplegic limbs in a case 
where the motor paralysis had been complete for nearly 
four years, and another case in which there has recently 
been a partial recovery where the sensory paralysis had 
existed for two years and the motor paralysis for ten 
years. Recent work by various surgeons in forcible 
straightening of kyphotic spines under anesthesia seems 
to warrant the expectation that this operation will give 
immediate relief from the paralysis in the vast majority 
of cases. Relapses of the paraplegia may occur, but 
fortunately are not frequent. 

The treatment of spondylitis, like the treatment of 
chronic disease of the arms and legs, is chiefly mechan- 
ical, but occasionally it is operative. The mechanical 
treatment may be divided into three stages : 1. Correc- 
tion of the deformity ; 2. Physiologic rest of the 
diseased area ; 3. Restoration of function. 

Correction of the Deformity. — From the earliest times 
eff'orts have been made to correct spinal deformities. 
Hippocrates (460-357 B. C.) treated spinal deformities 
occasionally by succussion, but he appears generally to 
have preferred treatment by forcible traction and coun- 
tertraction, with direct pressure upon the gibbosity. 



54 

Henry Heather Bigg,^ quotes the following from Dr. 
Adams' translation of " The Genuine Works of Hip- 
pocrates " : — 

" Those cases in which the gibbosity is near the neck are 
less likely to be benefited by these succussions with the head 
downwards, for the weight of the head and tops of the 
shoulders when allowed to hang down is but small ; and such 




Fig. 34. 



-The treatment of spinal deformities by suceussion. From tlie Venetian 
edition of Galen. Quoted in Bigg's " Orthopraxy." 



cases are more likely to be made straight by suceussion with 
the feet hanging down, since inclination downwards is greater 
in this way. When the hump is lower down it is more likely 
that suceussion with the head down should do good. If one 
should think of trying suceussion it may be applied in the 



Orthopraxy." J. & A. Churchill, London, 1877. 



55 



following manner : The ladder is padded with leather or linen 
cushions, laid across, and well secured to one another, to a 
somewhat greater extent, both in length and breadth, than 
the space which the man's body will occupy ; he is then to 
be laid on the ladder upon his back, and the feet at the 
ankles are to be fastened, at no great distance from one an- 
other, to the ladder with some firm soft, cord; and he is 
further to be secured 
in like manner both 
above and below the 
knee and also at the 
nates; and at the 
groins and chest loose 
shawls are put around 
in such fashion as not 
to interfere with the 
effects of succussion ; 
and his arms are to 
be fastened along his 
sides to his body, and 
not to the ladder, 
\Mien you have ar- 
ranged these matters 
thus you must hoist 
up the ladder, either 
to a high tower or to 
the gable end of a 
house; but the place 
where you make the 
succussion should be 
firm and those who 
perform the exten- 
sion should be well in- 
structed so that they 
may let go their hold 
equally to the same 
extent, and suddenly, 

and that the ladder Fig. 35. — Forced correction of spiual curvature by 
■mav npifhpr fnmhlp traction and countertractioD, and direct pres- 

luay ueitnei tuniDie g^^^.^ ^y lever. From the Florentine edition 

to the ground on of Galen. Quoted in Bigg's " Orthopraxy." 

either side nor they 

themselves fall forward. But if the ladder be let go from a 
tower, or the mast of a ship fastened to the ground with its 
cordage, it will be still better, so that the ropes run upon a 
pulley or axle-tree." 




For the treatment of the gibbosities of spinal caries 
by extension Hippocrates recommended that 

" something like an oaken bench of a quadrangular shape is 
to be laid along at a distance from the wall in which a groove 



56 

has been previously scooped, which will admit of persons to 
pass around if necessary, and the bench is covered with 
robes, or any thing else which is soft, but does not yield 
much." 

The patient after being stoved and bathed v^ith hot 
water is to be stretched upon the board on his face, 
the arms being laid along and bound to his body. 

Next 

"the middle of a thong which is soft, sufficiently broad and 
long, and composed of two cross straps of leather, is to 
be twice carried along the middle of the patient's breast, 
as near the armpits as possible ; then what is over of the 
thongs at the armpits is to be carried round the shoul- 
ders and afterwards the ends of the thong are to be fast- 
ened to a piece of wood, resembling a pestle ; they are 
to be adapted to the length of the bench below the patient, 
and so that the pestle-like piece of wood resting against 
this bench may make extension. Another such band is ap- 
plied above the knees and ankles, and the ends of the thongs 
fastened to a similar piece of wood ; and another thong, 
broad, soft, and strong, in the form of a swathe, having 
breadth and length sufficient, is to be bound tightly around 
the loins as near the hips as possible ; and what remains of 
the swathe-like thong with the ends of the thongs must be 
fastened to the piece of wood placed at the patient's feet, 
and extension in this fashion is to be made upwards and 
downwards, equally, and at the same time in a straight 
line." 

It is further recommended to press the pahn of the 
hand upon the hump while extension is being made; 
or a person may sit upon the hump while extension is 
being made, rising from time to time and letting him- 
self fall back upon it, or the foot may be placed upon 
the hump and the entire weight of the body brought 
gradually to bear upon it. Or better still, a lever may 
be used, one extremity of which is fixed in a hole in 
the wall, or in a piece of wood fastened to the ground. 
This lever is brought across the hump, a cushion being 
interposed and firmly pressed down while extension is 
made. 

Galen (130-200 A. D.) appears to have followed very 
closely the methods of Hippocrates. His influence 



57 

was paramount for more than 1300 years. In the 
Venetian edition of Galen's works will be found an 
illustration showing the method of performing succus- 
sion. In the Florentine edition is an illustration show- 
ing pressure upon the gibbosity by means of a lever 
during extension and. counterextension by a windlass 
device. 

Ambroise Pare (1517-1590) followed the teaching of 
Hippocrates in all essential particulars. He differs only 
in setting aside the pestle-like lever of Hippocrates and 
the windlass device of Galen for direct manual traction 
and counter traction, and in giving certain instructions 
for exerting pressure upon the projecting portion of the 
spine. He adds, moreover, directions for the applica- 
tion of splints to the back when the distortion has been 
reduced. The illustration that he gives shows the 
patient laid upon his face on a table, bound with towels 
under the armpits and about the hips, and by means of 
these extension is made, but not violently. During the 
extension pressure is made upon the projecting verte- 
brae by the hands; but if pressure exerted in this man- 
ner fails to restore the protruded parts, then it 

" will be convenient to wrap two pieces of wood, four fingers 
long Hnd one thick, more or less, in linen cloths, and so to 
apply one to each side of the dislocated vertebrae, and so with 
your hands to press them against the bunching forth vertebrae 
until you force them back into their seats, just after the man- 
ner vou see it before delineated." ("Orthopraxy." Henry 
Heather Bigg. 1877.) 

These ancient methods were long since abandoned 
and have only been saved from total oblivion by oc- 
casional mention as examples of curious and barbarous 
procedures. Reference is here made to these methods 
for comparison with the work recently done by Calot 
and others, to be described later on in these pages. In 
1874 Sayre, of New York, began the treatment of 
spondylitis with the use of the plaster-of-Paris jacket, 



58 

applied with the patient partially suspended, claiming 
by that means to correct the deformity in some con- 
siderable measure. Orthopedic surgeons in general, 
however, denied that the true curve or angle at the 




point of disease was in any way affected by this treat- 
ment, and that the only straightening of the spine 
effected by it occurred in the compensatory curves 
above and below the area of disease. The recent results 
from forcible straightening of spinal curvatures seem 



59 

to demonstrate that Sayre's early claims were well 
founded. 

Charles Fayette Taylor, ol New York, followed with 
claims of gradual straightening by the antero-posterior 
leverage spinal brace ; and his son, Henry Ling Taylor, 
has shown tracings of many cases treated with the 
Taylor brace and a more or less prolonged period of 
recumbency, in which some degree of straightening 
has taken place. 

Following the treatment recommended by the late Dr. 
Buckminster Brown, of Boston, we believe that one of 
us (J. R.) w^as the first to report a case of cervical spon- 
dylitis in w^hich a well-marked angular deformity was 
completely corrected by horizontal traction, the patient 
being in bed. 

The attempts at gradual straightening by the leverage- 
brace, and by traction, with the patient recumbent, 
have been successful so many times and in the hands 
of so many different men that we may speak very con- 
fidently as to the results. They are briefly as follows : 
So long as the disease is active, deformity from disease 
in the cervical spine can be wholly effaced; deformity 
in the upper half of the dorsal region can rarely be 
reduced ; in the lower half of the dorsal region it can 
usually be somewhat reduced ; in the lumbar region it 
can usually be greatly reduced and sometimes entirely 
effaced. 

Recently, efforts have been made, and successfully, 
to straighten these spinal deformities by the exercise of 
considerable force, the patient being completely anes- 
thetized. For many years, since the introduction of 
ether and chloroform, surgeons have been accustomed 
to straighten deformities due to disease at the joints of 
the legs and arms by the use of considerable force, but 
to Dr. Calot, of Berck-sur-Mer, is due the credit of sug- 
gesting and employing the same procedure in deform- 



60 

ities due to disease in the spinal bones. Calot says 
that he was not satisfied with the results of the usual 
methods of treating Pott's disease: that he found the 
deformities under the usual methods of treatment 
growing progressively worse. This same ex23erience 
has been the common lot of all surgeons who depend 
upon a surgical instrument-maker to measure for and 
apply spinal braces, and it has too often been the 
experience of those depending upon the plaster-jacket 
as a support in ambulatory cases. 

Calot has been followed, with certain modifications, 
by very many of the Continental surgeons. It is not 
necessary here to specify them or their modifications. 
Briefly they are as follows : In recent cases the 
straightening is effected by longitudinal traction by the 
hands of assistants or by mechanical devices, while the 
operator makes downward pressure upon the kyphosis, 
the patient lying prone. In older cases operative 
measures are added. The soft parts are cut through 
and the bones divided by a chisel in one or more 
places ; carious foci, if within reach, are scraped out ; 
then the spine is straightened, and the spinous pro- 
cesses are wired to each other to maintain the correct 
position. This idea of immobilization by wiring the 
spinous processes appears to have originated with Dr. 
B. Hadra, of Galveston, Texas, who, in 1890, wired the 
spinous processes in a case of fracture of the spine. 
The immediate result was so good that Hadra recom- 
mended it in the treatment of Pott's disease in a paper 
read before the American Orthopedic Association in 
1891. Hadra's wiring for fracture ultimately proved a 
failure, and, so far as we know, it has not been at- 
tempted for Pottos disease in this country. European 
surgeons appear to be becoming more conservative in 
their work in forcibly straightening these spines, since 
deaths have occurred from tuberculous meningitis and 



61 

general tuberculosis arising apparently from dissem- 
ination of the disease through tearing through the walls 
of the tuberculous focus, as has occurred after forcible 
straightening at the hip and knee. 

At the present time the deformity, if it be at all con- 
siderable, is straightened at several operations instead 
of at one, and cutting operations are avoided. Plaster- 
of-Paris is generally used as the means of retention. It 
may be put on while the patient rests upon two blocks, 
one under the hips and the other under the upper part 
of the chest, traction and countertraction being main- 
tained; or the patient may be suspended by the feet 
during the application of the jacket. Foot-suspension 
requires fewer assistants and is safer when chloroform 
is used as the anesthetic ; the objection to it is that the 
abdominal contents are displaced upward to an unnatu- 
ral and uncomfortable degree. The horizontal position 
is objectionable chiefly because it favors an uncom- 
fortable degree of lordosis when the disease is dorsal, 
and because it is a difficult position when the head 
needs to be embraced by the plaster-dressing. Unless 
the head be included in the dressing, recurrence of the 
deformity may be expected in all cases in which the 
disease is at or above the ninth dorsal vertebra. After 
forcible correction of the deformity the patient must be 
kept in bed for many months, as no mechanical device 
can be relied upon to retain the spine in the corrected 
position if patients are allowed to walk around. 

We have performed this operation of forcible straight- 
ening a sufficient number of times to warrant us in 
speaking from personal experience. The patient is fully 
anesthetized, perferably by chloroform. The patient is 
then turned prone upon the table. One assistant, in the 
case of a child, makes traction upon the legs ; another 
makes traction upon the arms, and the anesthetizer 
makes gentle traction upon the head. The operator, 



62 

with his hands upon the kyphosis, directs the gradual 
increase of the traction as the deformity yields, usually 
with considerable tearing and crackling, which can be 
distinctly felt and sometimes be heard. In recent cases 
little or no pressure need be made by the operator to 
effect the straightening of the spine; in cases of longer 
duration the surgeon may find it necessary to exert 
very considerable pressure. Each operator must judge 
of the amount of force that can be safely employed in 
each case. When the deformity is in the dorsal region 
and associated with a protruding sternum it will be 
convenient to place a block under the hips and another 
under the sterno-clavicular articulation. When the 
straightening has been effected the patient is clothed in 
a closely fitting stockinet shirt ; quarter-inch felt pads 
must be placed over the iliac crests, and from half-inch 
to inch pads of felt must be placed upon the transverse 
processes on each side of the kyphosis, as close as 
possible to the spinous processes, to guard against press- 
ure-sores, and then the plaster-jacket is made. Such a 
jacket must be made longer than the ordinary plaster, 
jacket used in ambulatory cases. In cases of lumbar 
disease it must extend downward on the thighs below 
the greater trochanters so far that the patient cannot 
sit upright, and in the presence of disease at or above 
the ninth dorsal vertebra it must extend up to and in- 
clude the head. It has been claimed that the jacket 
thus applied maintains the longitudinal extension, but 
this is doubtful ; it does, however, almost wholly pre- 
vent antero-posterior bending, and thereby acting as a 
lever, it prevents any considerable return of the de- 
formity. The application of a plaster-jacket, including 
the head, while the patient is profoundly anesthetized 
and horizontal traction and countertraction are main- 
tained, requires many assistants and is rather difficult ; 
if sufficient assistants are not available it will be best 



63 

to suspend the patient by the feet, or by the knees, and 
apply the jacket with the head pendant. When 
patients are to be suspended by the feet or the knees 
plaster-casts must be put on the feet, or the knees, the 
day before the operation, so that the supporting straps 
or bandages may not constrict the limbs. When the 
head is to be included the hair is to be cut short, or the 
head shaved, and then wrapped thickly in bandages of 
cotton-wadding or wrapped in oakum held by an 
ordinary roller-bandage. Pressure-sores readily form 
on all parts of the head and they may form over the 
prominent sternum, or indeed over any bony point. 
After observing the recent work of Goldthwait, of 




Fig. 37.— Ridlon's Bridge for supporting a patient during application of 
plaster-jacket. 

Boston (May, 1898), who utilizes the weight of the 
patient above the diseased area to partially correct 
the deformity, without anesthesia, and his stretcher- 
frame for holding the patient during the appli- 
cation of the plaster jacket, one of us (J. R.) has 
made use of the following procedure : After the spine 
has been straightened forcibly, as already described, 
and the patient is clothed in the stockinet shirt, he is 
laid supine upon two light steel bars supported by two 
sheet-steel rests that stand upon a table. The steel 
bars are bent to fit the straightened spine from the 
apex of the kyphosis downward, and they are separated 
just far enough to make pressure upon the transverse 



64 

processes. The sheet-steel stands that carry the parallel 
bars are narrowed at the top to ^ inch on each side of 
the bars. Laid supine upon these bars, with the part 
of the body above the kyphosis extending beyond 
their ends, the weight of the upper part of the 
body will straighten the deformity more than it can be 
straightened in any other way during the application 
of the jacket. A half-inch pad of felt is placed between 
the bars and the kyphosis, and quarter-inch pads over 




Fig. 38.— Patient resting on Ridlon's Bridge in position for the application 
of a plaster-jacket. 



the iliac crests and over the upper part of the sternum. 
The plaster-jacket is then made, including the parallel 
bars. When it has hardened the patient is turned 
over prone, and the parallel bars are pulled out. This 
leaves a weak place at the back just above the angle of 
the deformity ; and this can be strengthened by a few 
half turns of a plaster-bandage. In cases in which the 
disease is in the dorsal region above the ninth verte- 
bra, the jacket can be built up in front under the chin 
of the extended head and the whole head need not be 



65 

included in the plaster-dressing. This bridge-device 
for supporting the patient, which only weighs 2 or 3 
pounds, can be used in place of Goldthwait's stretcher- 
frame in applying plaster-jackets when the patient has 
not been anesthetized, and in all cases it is far more 
convenient for the surgeon and more comfortable for 
the patient than any form of suspension. 

The second stage of treatment may be summed up 
in the term physiologic rest. This means the nearest 
possible approach to immobilization of the diseased 
area, its protection from jars and concussion, and its 
relief from weight-bearing until consolidation has be- 
come well established. Immobilization is sought for, 
and more or less perfectly attained by rest in bed, with 
or without traction, and by the application of a brace 
or corset ; some of these devices by their leverage- 
action protect the diseased area from a certain degree 
of weight-bearing and jar during locomotion. Whether 
the patient should be treated with brace or jacket, or 
in bed with or without traction, will depend not only 
upon the individual case and its personal peculiarities, 
but also upon the family and the general surroundings, 
and the skill of the surgeon himself in the use of this 
or that special appliance. One surgeon may be able to 
fit a brace well and manage it skilfully, but be un- 
able to make a satisfactory plaster-jacket ; another may 
not be able to work at all well with tools and yet make 
an elegant and well-fitting jacket. The methods of 
treatment are of far less importance than a correct ap- 
preciation of the principles involved, and the patience 
requisite to carry them out to the very end. In the 
hands of one of us the best results have been obtained 
by the antero-posterior leverage-brace ; in the hands of 
the other a cuirass has been most serviceable. The 
latest form of the Taylor brace is perhaps the most cor- 
rect theoretically, but in our hands it is not readily ob- 






66 

tained and fitted. Most surgeons probably now use some 
form of jacket of plastic material, of which the Say re 
pattern is the example best known and most readily 
made. Each of these will be hereafter described. 

Treatment should be commenced at the earliest pos- 
sible moment, and must be persisted in until cure is 
effected. A case is cured only when the spine will bear 
the superincumbent weight without pain or evident 
weakness in any posture, and continue so without any 
increase in the deformity. 

Treatment by Recumbency. — This mode of treatment, 
by recumbency, in its effective application, is so exact- 
ing to the patient as to be well-nigh impossible. It 
calls for the most careful nursing and hence is wholly 
unsuited for the poorer population. It requires that 
the bed should be flat, smooth, firm, and without a 
pillow, and the patient so secured by straps that he 
cannot sit up, twist or turn. Thus, a strap of webbing 
or strong bandage is passed across the bed beneath the 
patient's shoulders, and fastened to the bed-frame on 
either side ; upon this strap are strung two loops 
through which the patient's arms pass, and these are 
connected the one with the other by a strap across the 
chest. The pelvis is secured by abroad belt around it, 
from the sides of which straps pass to the sides of the 
bed-frame and are there fastened. The patient must 
not be allowed to sit up for food, for the use of the bed- 
pan, or for any other purpose ; nor must he be taken 
from bed for bathing, for changing of sheets or cloth- 
ing, or for the turning of the mattress, if the best effects 
of recumbency are to be secured. To fail in strictly 
following these directions will cause the breaking up 
of the new bone-formation about the carious vertebrae, 
a return or an increase of the deformity, or it may pro- 
long the paraplegia, if present, and perhaps render it 
incurable. It will be readily seen that although the 



67 



surgeon is saved labor, it is very difficult to carry out 
this treatment for any considerable time ; in fact, prac- 
tically impossible to carry it to a successful result in 




any but exceptional cases. So-called "treatment by 
recumbency " often means that the patient lies in bed 
when he chooses, sits up when he pleases, or gets up 
and walks when he can. Under such conditions it is 



68 

not surprising that the deformity increases, that ab- 
scesses are frequent, and the duration of the disease is 
prolonged. 

To increase the efficacy of recumbency various other 
means have been employed. Traction is used, both 




Fig. 40. — Canvas cot for treatment by recumbency. 



for its effect in reducing the deformity and preventing 
the patient from sitting up in bed. A sling is attached to 
the patient's head and from it a cord is carried over a 
pulley at the head of the bed to a small weight of from 
J to i or 2 pounds. Slings may be made of leather or 
of cloth, and are constructed upon one or two general 



69 

plans ; either that which is used in the ordinary sus- 
pension-apparatus, or one made by buckhng a band 
across the forehead and below the occiput and attach- 
ing another above each ear to pass over the head, to 
which is attached the pulley-cord. This leaves the 
chin free, prolonged use not causing recession of the 




Fig. 41.— Bradford's frame for treatment by recumbency. 

chin, and in exquisitively sensitive cases of cervical 
spondylitis the patient can eat with less motion and 
less pain. 

Traction can be used with advantage only in cases 
confined to bed, being especially advantageous in the 




Fig. 42.— Elastic head-traction to bed- frame. 



presence of cervical spondylitis, less so in lumbar and 
dorsal disease. It is of value when inflammation is 
progressive and when paraplegia complicates. It is an 
efficient aid in reducing to a minimum the pain and in- 
crease of deformity from muscular spasm during the 



70 

formation of an abscess. Traction does not appear to 
separate healthy articular surfaces or diseased ones after 
the reparative process has commenced. It does, however, 
at times reduce the deformity, apparently by separat- 
ing the contiguous carious surfaces, and this without 
pain or any ascertainable untoward results. 

In cases successfully treated by Mr. Jones the little 
patients are strapped on canvas stretched on a frame 
that rests on the bed on four short legs. Straps are placed 




Fig. 43. — Fixed traction from head to bed-frame, with 
weight- an d-pulley traction from pelvic girdle. 



that fix the shoulders and thighs to the canvas, and 
holes opposite the anus and perineum assure easy egress 
to excretions. By this device the patients can be 
moved about without interfering in any way with the 
diseased vertebrae. Sayre uses the wire cuirass with 
head-sling and traction from the feet; this apparatus 
cannot be readily obtained and is expensive. Steele, 
of St. Louis, attains the same end by a portable 
stretcher-bed, consisting of a forged, oblong frame of 
flat bar-iron, made somewhat longer and slightly wider 
than the patient, over which are snugly stretched two 
pieces of strong canvas, one reaching from the buttocks 
to the top of the frame and the other from just below 
the buttocks to the bottom of the frame, the space be- 
tween the two being left for the use of the bedpan. 
Upon this stretcher the patient is placed, strapped down 



71 

at the shoulders and hips, and traction is made from 
the head-sling upward, to a flange at the top of 
the frame, by means of an elastic or inelastic strap, 
and downward by elastic or inelastic straps attached to 




strips of adhesive plaster applied to the patient's legs, 
to two flanges at the bottom of the frame. The pa- 
tient thus lying on the frame can rest upon the bed or 
be carried about without discomfort of motion to the 



72 



spine. The iron- work of the frame can readily be 
done by any blacksmith, and the covering by the fam- 
ily of the patient ; all should cost but very little. 

The surgeons of the Children's Hospital in Boston 
reduce the expense still further by making the frame 
of iron gas-piping, and obtain traction from head and 
legs by the ordinary weight and pulley to the head and 




Fig. 45. — Sayre's cuirass. 

foot of the bed. A gaspipe frame can be made to 
take the place of Steele's frame by having pieces of 
smaller pipe set upright in the middle of the bar at the 
head and like pieces at each of the corners at the foot. An 
excellent device is to slightly modify a Thomas double 
hip-splint by putting the parallel bars a little closer to 
each other and extra side wings so as to restrain all lat- 



73 

eral motion at the hips. A piece of strong leather can be 
stretched from one main stem to the other to form a sling 
for the spine and make it possible to lift and move the 
patient as one piece. Without some such plan, to turn 
a patient over for cleaning or other purposes, means 




damage, slight or severe, to the carious column. 
Thomas' modification of the Bauer support offers 
admirable assistance to ♦bed -treatment if two bars be 
added which extend to the knees and thus fix the 
thighs. This appliance is easily borne and its applica- 



74 

tion offers no difficulty. The irregularities of the bed are 
thus obviated, and the greatest leverage can be employed 
to modify existing and prevent threatening deformity. 
Another device of simple construction is the Phelps 
plaster-bed. It is constructed in the following manner: 
A J-inch board is cut roughly to the form of the patient, 
with the legs somewhat separated ; foot-pieces are put 
on at the bottom and an iron flange is set in at the top 
to carry the head-sling ; the upper surface of the board 
is upholstered and the patient is laid thereon ; then he 
is wrapped from the shoulders downward, together with 
the board, in plaster-bandages ; before the plaster fully 
hardens the front is cut out, leaving a plaster-trough, 
the cut edges of which are bound, and in which the 
patient can comfortably lie. 

Treatment with the Plaster-of- Paris Jacket. — This aims 
at immobilization after the patient has gained a position 
of greatest comfort by partial suspension. The opponents 
of the plaster-jacket treatment have asserted on the 
one hand that, by suspension, the carious surfaces are 
separated and the patient's life thereby endangered ; 
and, on the other hand, that suspension is of no use 
inasmuch as it does not straighten the spine at the 
area of disease, but only apparently elongates it by 
straightening the normal curves. It appears to us that 
neither of these objections has any foundation in fact. 
There appears to be no evidence that separation of 
the carious surfaces by partial suspension has ever 
been of the slightest harm to the patient; and it has 
not been claimed by the advocates of suspension that 
it would straighten the curve of disease after reparative 
consolidation had at all advanced. Portions of curva- 
tures and whole curvatures due to involuntary muscu- 
lar spasm, and angles due to loss of bony tissue in the 
vertebral bodies can, before any considerable reparative 
action has taken place, be in a measure sometimes 



75 



totally rectified by well-judged and carefully executed 
partial suspension. - 




Fig. 47. — The hand-knee posture for applying a plaster-jacket. 

The plaster-jacket can, of course, be applied without 

2 When the manuscript of the part of this chapter relating to the plaster- 
jacket was submitted to Dr. Sayre for suggestions and corrections he told Dr. 
Ridlon that a patient had been killed in Berlin by the breaking internally of an 
abscess-wall during complete suspension with weights attached to the feet and 
during chloroform-narcosis. Mr. Jones adds to this his experieoce in two cases, 
neither of which was published at the time. He was called to see a patient who 
had returned home from one of the hospitals after having been suspended dur- 
ing the application of a jacket for upper dorsal curvature. The patient, who 
had been perfectly well up to the period of suspension, died 2 hours after leaving 
the hospital, after complaining of pain in the limbs and suffering great respira- 
tory difficulty. In the other case paraplegia resulted suddenly, being almost 
complete in 24 hours. In both cases suspension had been too complete, although 
in each case a surgeon of repute superintendel the application. Dr. Sayre ex- 
presses a doubt as to the possibility of fully correcting any true angle by the 
suspension-treatment. 



76 

suspension of the patient, but unless the spine be put 
in a position of greatest comfort to the patient the object 
for which the plaster-jacket was designed is not attained, 
and failure to gain good results should not be accredited 
to the jacket- treatment. Surgeons are much too prone 
to modify methods and mechanical appliances without 
duly appreciating the principles of the apparatus that 
they ingeniously ''improve" and label with their 
names. It is safe to say that of the thousands who have 
used the plaster-jacket in the treatment of spondylitis 
very few have ever given due thought to the teaching 
of Dr. Sayre to " suspend the patient until the point of 
entire freedom from pain is reached, stop there, and at 
once apply the jacket." In this connection, however, 
it must be remembered that many patients do not 
complain of pain, even during the period when the 
angle is on the increase. 

Some very young children are frightened by suspen- 
sion, and in their case it seems wise to forego its use 
until a certain degree of confidence has been established. 
In a few cases it is not well borne, the patient showing 
such a tendency to syncope that one does not like to 
repeat the experience. In such cases, prior to fixing 
with plaster, the hammock of Davy may be employed, 
or the patient may be placed in the hand-knee posture 
and the spine guided into the best possible position by 
gentle manipulation. If the hammock of Davy be 
used it must be drawn tight ; otherwise the sagging as 
the patient lies with the face downward will give an 
uncomfortable position when the jacket has set and the 
patient stands. 

The appliances requisite for suspension are as fol- 
lows : A strong hook set into a beam, or a tripod, or 
crane. To the hook are attached a block and tackle, 
which support an iron cross-bar from 12 to 18 inches 
long, grooved transversely for adjusting the leather 
head-sling, or collar, and arm- slings that hang from 



77 

it. The collar and arm- slings are so adjusted upon 
the patient that, when he stands directly under the 
cross-bar and traction is made upon the pulleys, the 
force is expended equally upon the head and arms. 
For the jacket the plaster-bandages should be made 
by the surgeon or under his immediate supervision, 
for we know of no place where even fairly good ones 
can be purchased. Dr. Sayre has them made from 




Fig. 48.— Suspension-apparatus. 

cross-barred crinoline, in lengths of from 3 to 5 yards, 
torn into strips 2, 4, or 6 inches wide, according to the 
size of the patient, care being taken to tear off the 
selvage from the fabric.^ 

3 The starch used in stiffening the crinoline in no way interferes with the set- 
ting of the plaster, but all specimens of cross-barred crinoline that we have found 
for many years past have been stiffened with some glutinous substance that 
delays the setting of the plaster. Such stiffening must be washed out and the 
goods ironed before being used. For some time past we have used a crinoline, 
not cross-barred, made especially for use in plaster-bandages by The H, B. Claflin 
Co., of New York, and known as " H " crinoline. It comes in pieces of 27 inches 
wide and 12 yards long, and costs 45 cents per piece. A piece is sufficient for 18 
bandages, 3 inches wide and 6 yards long. 



78 

To make plaster-bandages the strips of crinoline are 
spread upon the flat surface of a table or shallow tray 
and the best quality of dental plaster- of-Paris is thor- 
oughly rubbed in, removing the excess, and rolling the 
bandage rather loosely as the plaster is rubbed in. A 
bandage rolled tightly requires too long a time to be- 
come thoroughly wetted, while the center of one rolled 
loosely and with too much plaster between the rolls 
easily slips when wetted and becomes twisted and 
tangled. Too much plaster between the rolls of the 
bandage is a very common fault, and needs to be 
guarded against. It is our experience that bandages 
made in any other way and from any other material, 
however satisfactory for ordinary plaster-splints, will be 
found of little use for making really durable plaster- 
jackets. From 7 to 15 bandages will be required to 
make a jacket; if the jacket is to be cut down it should 
not be made too thin. For soaking the bandages a pail 
is used with sufficient tepid water to cover, by 2 or 3 
inches, the widest bandage when standing on its end. 
It will not be necessary to add salt or alum to the water 
to hasten the setting ; nor should the water be too hot. 
The plaster-sediment left in the bottom of the pail in 
which the bandages have been soaked, should not be 
used to rub into the jacket, as it will greatly delay the 
setting of the plaster and even soften that which is 
already set. A competent assistant is of the greatest 
importance, and he should rapidly and carefully smooth 
out every wrinkle and rub well in every layer as it is 
laid on. 

The patient should be clothed in a seamless, skin- 
fitting knitted vest, made long enough to reach below 
the middle of the thighs, and well pulled down ; it 
should fit without a wrinkle or a loose place. The sur- 
gical-instrument shops usually carry wool shirts of this 
order, but recently we have generally used tubular 



79 



stockinet of cotton of gray color. This stockinet can 
be obtained of the knitting-factories in pieces of any 




Fig. 49. — Plaster-jacket applied with the 
patient partially suspended. 



number of yards, and can be cut in any required length. 
It is much less expensive than the wool vests. All other 



80 

clothing should be removed down to the level of the 
greater trochanters. 

If the patient be a woman or an adolescent girl, breast- 
shields, or in lieu of these pads of cotton-wadding of 
proper size, should be placed between the breasts and 
the shirt ; and if the jacket is to be made removable a 
strip of zinc or block-tin 2 inches wide and long enough 
to reach from the neck to the pubes should be placed 
under the shirt for protection to the patient when 
rapidly cutting off the jacket. On the outer side of the 
shirt pads of felt should be placed over the iliac crests 
and long, narrow strips along each side of the spinous 
processes included in the kyphosis. The floor should 
be covered with a sheet ; and two chairs placed for the 
surgeon and his assistant. 

Now, all being ready, the patient should stand be- 
neath the suspension-apparatus while the surgeon ad- 
justs the collar and arm-slings, and suspends him to 
the point of comfort, and no further. The assistant sits 
in front and grasps with his knees the thighs of the pa- 
tient and steadies him. The surgeon sits behind, places 
a bandage on end in the pail of water and waits until 
the air-bubbles cease to rise ; he then puts in a second 
bandage, squeezes out the superfluous water from the 
first, and rapidly and smoothly winds it around the 
patient's waist, and from there works downward over 
the iliac crests to a level with the greater trochanters ; 
then he works upward again, each turn of bandage 
overlapping the former by two-thirds of its width, until 
a point is reached at the back and front well above the 
level of the axillse. The assistant must smooth out all 
folds and rub each layer well into the preceding one. 
In this way the bandages are laid on until a sufficient 
thickness has been attained. Then with a well-sharp- 
ened knife the jacket is trimmed out under the arms 
and at the flexures of the thighs, so that the patient may 
afterwards sit with comfort. 



81 

By tliis time the jacket will usually have become 
suificiently hard to permit of a discontinuance of the 
suspension. The patient should then sit quietly until 
the setting of the plaster is quite complete. If the 
plaster sets slowly, or if for any reason the time of 
suspension has to be shortened, the surgeon, placing 



Fig. 50. — Ridlon's plaster-knife, made by Wostenholm, of Sheffield Eng., and 

imported by J. Curley & Bro., 6 Warren St., New York City. This knife 

is specially shaped and specially hardened for plaster-work. 

his hands under the patient's arms, lifts him while the 
assistant, after removing the collar and arm-slings, sup- 
ports the patient by the thighs ; thus he is placed prone 
upon a couch to await the completion of the work. But 
if the jacket is to be made removable it is cut down 
from neck to pubes, while the patient is still suspended, 
carefully sprung off the patient, its cut edges brought 
accurately together and held by an ordinary gauze or 
muslin roller-bandage. The jacket is then set aside to 
dry — it will usually take 2 or 3 days — or it may be 
rapidly dried in an oven or over a range, in which case 
it must be carefully watched less it become brittle. 
When dry it is tried on the patient during partial sus- 
pension, and trimmed wherever it may be necessary to 
render the patient quite comfortable ; the outer and 
inner layers of the shirt are stitched together over the 
cut edges in front on either side, and here on each side 
on the outer surface of the jacket are sewed two strips 
of strong leather, previously provided with lacing-hooks 
set at intervals of about an inch. The patient is then 



82 

clothed in a well-fitting undervest — those made to meas- 
ure and of Angora wool, and skin-fitting are the best — 
suspended as before, and the jacket applied and laced. 
The jacket must not be removed at night, or at any time 
except during partial suspension and in the presence of 
the surgeon. 

For disease above the eighth dorsal vertebra, the 
jacket alone does not give sufficient support to prevent 
the steady progress of the deformity. When the 
disease exists between the first and eighth dorsal verte- 
bra a jury-mast should be used to support the weight 
of the head, and more especially to prevent it from 
drooping forward. 

The jury-mast consists of strips of tin, perforated in 
opposite directions, and joined to 2 steel uprights, at 
the back, bent to fit the outline of the patient. The tin 
strips, 2 on either side for a child and 3 for an adult, 
extend laterally from the posterior steel uprights nearly 
to the median line in front, but not across the spine at 
the back, and with the posterior steel bars are worked 
in between the layers of the jacket during the process 
of construction. The posterior bars are curved at the 
top, approach each other and are joined into one by 
being welded to form the upright bar that passes up- 
ward over the top of the head. This bar is bent to 
approximately follow the contour of the neck and head, 
and may be lapped and fastened with screws at the back 
of the neck so as to be elongated at will. It ends di- 
rectly over the top of the head, and to its upper surface 
is riveted a cross-bar, turned up at the ends, from which 
depend the head-slings. The cross-bar being riveted 
by a single rivet, loosely set, the patient is able to turn 
his head from side to side at will. 

For disease in the cervical vertebrae it is customary to 
make use of the same appliance, but we have not found 
it to immobilize eff'ectively. 



83 



After the application of a permanent plaster-jacket 
no patient should ever pass from the surgeon's im- 
mediate control before 24 hours have passed in perfect 
comfort; any complaint of it hurting at any point, 
then or later, should be considered as a positive indica- 
tion for the removal of the jacket. 

The objections that may be urged against the plaster- 
jacket are chiefly its cost and the delusion that most 
surgeons labor under that it is a simple thing to properly 
apply it. It will be evident from the foregoing that it 




Fig. 51.— The jury-mast. 

is not the ideal treatment for dispensary -work if little 
time can be devoted to each patient and if every detail 
of cost is counted. A really good jacket will last from 
2 to 3 months if a laced one, or somewhat longer if 
permanent, but a growing child will require from 4 to 
6 jackets each year and the disease will require treat- 
ment from' 2 to 6 years. When to the cost of materials 
is added the value of the surgeon's time it will be 
found to be an expensive method of treatment. 

Grave objections, however, may be urged against 



84 

plaster-jackets improperly applied, as it seems to us 
they usually are, from observations based upon patients 
wearing jackets applied at hospitals and dispensaries 
and by the family-doctor. With few exceptions they 
have been permanent jackets, seldom padded, and never 
with felt, over the bony prominences, rarely carried 
high enough or sufficiently low, generally so loose that 
the hand can be readily passed under them, so lacking 
in power to immobilize that the patients give a history 
of steady and progressive growth of the deformity, 
and when used among those of our fellow citizens who 
have with reason been called the " great unwashed " 
have formed the pleasantest of homes for vermin of 
various sorts. 

One does not of course have the opportunity to re- 
move jackets applied by others from those patients who 
have done well and are satisfied with the treatment ; 
but from the other patients, those that have not done 
well and are not satisfied, jackets are rarely removed 
without pressure-sores being exposed. 

The Treatment of Spondylitis by the Antero-posterior 
Leverage Spinal Brace. — It is not necessary to describe 
the orignal Taylor brace, as it is no longer in use. The 
modifications of this brace by Dr. Taylor have all 
been designed to increase its efficiency; those intro- 
duced by others have generally been to reduce its cost, 
but the principles upon which they have all been used 
are the same, namely, immobilization of the spine at 
the area of disease by adjustable leverage, using the 
transverse processes of the vertebrse included in the 
kyphosis as the fulcrum. Braces have been made be- 
fore and have been made since the Taylor brace was 
devised, much like it in appearance, but generally dif- 
fering from it by separating the parallel upright bars 
so far that the leverage is brought to bear on the ribs, 
or they have attempted to combine traction with lever- 



85 

age and have thus failed to effectively apply the 
principle of making the leverage adjustable. 

By adjustable leverage in the treatment of kyphosis, 
it is meant that the brace is so constructed that by 
manipulating the bars by means of wrenches (at first 
it was by hinges and set-screws) the pressure over the 
transverse processes of the vertebrae composing the 
angle can be adjusted to a nicety and increased or 
diminished at will, it being anticipated that in certain 
cases and with the disease in certain localities the 
curve will gradually diminish and occasionally be 
entirely effaced by the leverage-action. 

It will be seen that the principle is essentially differ- 
ent from that underlying the use of the plaster-jacket. 
It does not suspend or partially suspend the patient, to 
gain the posture of greatest comfort or to improve the 
curve, but it applies the brace to the patient, with no 
attempt at improvement in his posture beyond that 
which is gained by lying down for a short time. More 
often than otherwise the patient is kept recumbent only 
so long as it takes to apply the brace, and, at times, 
when the disease is in the lumbar or in the cervical 
region, the brace is applied with the patient standing. 
This, however, is contrary to the teaching of Dr. 
Taylor, who never permits the patient to stand, either 
during the application of the brace or afterward, until 
convalescence is well established. 

The brace being applied, the chief aim is to im- 
mobilize the area of disease until a cure is effected ; 
meantime, if consolidation has not already taken place, 
it is attempted by gradually increasing the pressure to 
straighten the curvature, or at least check the progress 
of the deformity. The plaster-jacket aims at preserv- 
ing the reduction of deformity gained by periodic 
partial suspension ; the brace by its continued leverage- 
action is used to reduce the deformity ; both primarily 
aim at immobilization. 



86 

The advantages of the leverage-brace, over and above 
the efficiency with which it carries out the principles in- 
volved, are its comparatively small cost, its durability, 
and the little time and effort required of the surgeon 
to adjust it. A gunsmith, locksmith, or blacksmith of 
average ability can, under surgical supervision, be 
trusted to make it, and the result will be a more effi- 
cient apparatus than can be obtained from any of the 
great instrument-shops, where exorbitant prices and 
erroneous ideas as to construction are usually preva- 
lent. Braces with hard-rubber pad-plates and bearings 
will cost considerably more than if the rubber pieces 
be omitted, as the shaping of these hard-rubber pieces 
requires specially constructed molds and consumes 
much time. The brace, except when these pads are 
used, can generally be fitted in a few minutes ; it does 
not require frequent modification when once properly 
fitted ; and it rarely requires repair or material altera- 
tion ; it is comparatively light, cool, and easily kept 
clean and free from vermin, and the patient can, while 
recumbent, have it removed without risk and enjoy the 
pleasure of a sponge-bath. To be sure, it requires a 
certain degree of mechanical knowledge to rapidly and 
perfectly adjust it, but it appears to us a less difficult 
proceeding than to properly apply a plaster-jacket. 

The objections to the brace are that it is difficult to 
fit over a large kyphosis when the disease is in the 
upper dorsal and cervical regions, and even more so 
when any considerable lateral deviation exists; that 
prolonged use of the chin-piece may cause some reces- 
sion of the chin ; and that it makes no provision to 
prevent forward bending of the spine immediately 
above and below the area of disease. 

This brace is not an apparatus that can be bought 
ready-made at any instrument-maker's; it must be made 
for the individual, from measurement and pattern, and 



87 

with a definite end in view. A tracing is taken with a 
flexible metal tape along the line of the transverse 
processes — the line of the spinous processes always 
shows a much greater curve — and the tracing is copied 
upon strong paper, whereon are noted the position and 
direction of the shoulder-pieces, the place of the cross- 
pieces and the pad-plates, and the length and curve of 
the hip-piece. This diagram is the guide for the in- 
strument-maker; The resulting brace should accurately 
follow it ; but it usually requires a little refitting, which 
is accomplished by gradually bending it with wrenches 
made for the purpose ; or ordinary monkey-wrenches 
may be used. 

The pad-plates must be made to accurately fit the 
surface upon which they bear, and the remainder of 
the brace to approximately follow the outline of the 
back. The test of an accurate fit is a pink pressure- 
line upon the skin for the full length of the pad-plates 
after the brace has been worn, but with no place show- 
ing that the pressure is sufficient to create discomfort 
or to cause sloughing. The brace should be removed 
every day by the attendant while the patient is prone ; 
the back should be washed, rubbed with equal parts 
of spirit and water, and when dry dusted with some 
good talcum-powder or a mixture of powdered zinc 
oxid and starch. The brace should not be removed at 
night until the patient is convalescent. 

The ^form of brace now used by Dr. Henry Ling 
Taylorj consists of two parallel upright bars, two 
shoulder-pieces, one cross-piece, a hip-piece, a chest- 
piece, an apron, and the connecting straps and buckles. 
(Fig. 52.) Each of the parallel upright bars consists of 
three parts :Ja forged Jpad-plate to which are attached 
an upper and a lower bar by a half-hinge, and a set- 
screw forming a false hinge. This false hinge is placed 
opposite the angle of deformity, and the pad-plates are 



88 



made to extend well above and below the area of dis- 
ease. The lower sections of the npright bars extend 
downward to a point just above the posterior spines of 
the ilium ; the upper ones extend upward to the base 
of the neck, and in cervical disease to the upper part of 
the neck. The uprights are joined at the top by a 
short cross-piece ; opposite the lower border of the 
axillae is another cross-piece extending two-thirds across 
the back, and provided with buckles at the ends ; at 
the bottom the uprights are attached to the hip-piece. 

The hip-piece is forged from 
steel in the shape of an in- 
verted U. It extends across 
the back above the posterior 





Fig. 53. — Showing ear-shaped chest-pad 

spines of the ilia and then 
curves downward to the hollow 
behind the greater trochanter 
on each side. At each end of 
the hip-piece is a bearing-pad 
of hard rubber, where a buckle 
faces downward and another 
laterally. Across the buttocks, 
at about the beginning of the 
anal fissure, is buckled a broad 
strip of webbing, passing from one side of the hip-piece 
to the other. Between the axillary cross-piece and the 



Fig. 52.— Dr. H. L. Taylor's support. 



89 

hip-piece, equidistant from these pieces and from each 
other, two buckles are attached to each upright, and face 
laterally. The bearing-surfaces of the pad-plates are 
lined with hard-rubber plates molded to fit the contour 
of the spine. The shoulder-pieces are of steel, attached to 
the uprights at such an angle that they may pass across 
the shoulders close to the root of the neck, terminating 
somewhat above the clavicles in straps that pass down- 
ward to buckle on the chest-piece. The chest-piece 
consists of two ear-shaped or somewhat triangular pieces 
of thin sheet-steel faced with hard rubber, shaped to fit 
the contour of the chest below the clavicles and in front 
of the shoulders, and joined by two steel bars lapped 
and screwed so as to be of adjustable length. (Fig. 63.) 
From the lower end of each ear-shaped piece a webbing- 
strap passes downward to a buckle at the bend of the 
hip-band. The apron that holds the whole apparatus 
in place is made of two thicknesses of twilled muslin, 
and reaches on each side from the axillae to the iliac 
crests, and thence along the lines of the groins to the 
pubes, covering the entire front of the trunk as high as 
the arms. When the disease is situated at or above the 
seventh dorsal vertebra a head-piece is added, attached 
to the upper cross-piece by a pivot ; this head-piece may 
be of the form shown in Fig. 58. The head-piece is an 
ovoid ring forged from steel ; hinged on one side and 
fastened by a sliding-ring on the other. At the back a 
hole is made into which the pivot fits. Free lateral 
motion of the head-piece is permitted in dorsal disease, 
but in cervical disease this motion is restricted by a set- 
screw. In front, the chin rests in a hard-rubber cup, 
and at the back the occiput may be supported by two 
padded pieces of sheet-steel, screwed to the ring and 
extending upward. 

An inexpensive modification of this brace is used at 
the Children's Hospital in Boston. (Figs. 54 and 55.) 



90 



The pad-plates are omitted and in place of the hard- 
rubber bearings stiff, smooth leather is used. The 
apron is narrowed at the top and made to extend up- 
ward to the sternoclavicular junction, to take the place 
of the chest-piece of the Taylor brace. 

The form of antero-posterior leverage-brace that one 
of us (J. R.) has generally used, is shown in Figs. 56, 
57, and 58. It consists of a hip-band, two parallel up- 
rights, two cross-pieces, two shoulder-pieces, and two 
pad-plates. The hip-band is made of sheet-steel; it is 





Fig. 54. Fig. 55. 

Braces used at the Children's Hospital, Boston. 

from 1|- to 2 inches wide, and made of two pieces riv- 
eted together; the longer piece reaches from a point 
just above one great trochanter, across the back to a 
similar point on the opposite side ; the shorter piece is 
one-third this length, lies upon the middle portion of 
the longer piece, and is riveted to it at the middle and 
at each end, before it has been bent, as later on it 
must be, to fit the outline of the hips. This arrange- 
ment gives a straight middle third more rigid than the 
same thickness in one piece would be, and an easily 
bent third at each end. .At about an inch from each 



91 




Fig. 58. 



Fig. 57. 

end a hole is bored for the 
attachment of a buckle; and 
at each side of the middle, 
three pairs of holes are bored 
for the attachment of the up- 
rights. These holes are usu- 
ally cut with screw-threads 
so that the uprights may be 
screwed on ; they may, how- 
ever, be riveted. The hip- 
band is lined on the side 
next the patient with felt, 
and the whole is covered 



92 

with leather. The uprights are made of annealed steel, 
I-, -j^, or f inch wide, and gauge 9, 10, 11, or 12 in thick- 
ness, according to the size of the patient. They are 
each pierced by three holes at the bottom, each hole 
somewhat elongated and separate from the next by 
the same distance as the holes in the hip-band. By 
this arrangement the brace can be lengthened or short- 
ened half an inch. The pad-plates may be simply 
screwed on — holes having been pierced — or the arrange- 
ment of the pad-plates may be the same in detail as 
that shown in Fig. 56. In any case, the holes through 
the uprights, for screwing on the pad-plates, should be 
elongated to allow for easy fitting after any change in 
the curve of the brace. A hole is made in each up- 
right at a point opposite the lower angle of the scapula, 
for the attachment of the lower cross-bar, and another 
pair of holes, opposite the lower borders of the axillae 
for the upper cross-bar. At the top of each upright 
two or three holes are bored for the attachment of the 
shoulder-pieces; if they are to be screwed on and made 
adjustable, as is customary when no chin-piece is used, 
screw-threads must be cut in these holes ; when a chin- 
piece is used, the shoulder-pieces are riveted on. The 
pad-plates serve to strengthen the brace at the part of 
greatest strain ; if the false hinge is not required, they 
are cut from sheet-steel the same width as the upright 
bars and of a length sufficient to reach well above and 
well below the kyphosis ; they are pierced around the 
border with numerous holes for sewing on the pads, 
and, at about an inch from each end, a hole is bored 
and cut with screw-threads for receiving the screws 
that pass through the uprights. The cross-bars of steel 
are somewhat thinner and narrower than the main up- 
rights; in length, they extend for an inch or two to 
each side of the uprights when in position. They are 
pierced with a hole at each end for buckles, and with 



93 

three holes on one side and a slot on the other to allow 
of separation or approximation of the uprights. In 
putting on the buckles the rivet should pass from with- 
out inward, first through the leather and then through 
the steel, and be hammered into the hole in the cross- 
piece instead of being set into a bur. 




Fig. 59. — Protective brace for convalescent cases. No apron in front. 



The pads ijiat are to be sewed on to the pad-plates 
are small bags of canton flannel, filled with powdered 
cork and quilted flat to about f inch in width and f 



94 

inch in thickness. Good pads, however, may be cut 
from jDiano-felt. The shoulder-pieces are thinly padded 
on the side next the patient and covered with leather; 
at the end of each a tab of leather is riveted, and to 
these the shoulder-straps are sewed. The shoulder-straps 
may be of webbing covered with flannel, but they are 
better when made from a roll of blanketing or thin felt 
and covered canton flannel, and terminating in a 
short piece of webbing which buckles to the lower 
cross-piece. The apron is made of two thicknesses of 
twilled muslin, and reaches from the lower part of the 
abdomen to the level of the axillae in front, and from 
the crests of the ilia to the axillae laterally. Across the 
bottom is sewed a strong strap of webbing covered with 
canton flannel ; this fastens to the buckles of the hip- 
band on each side. At each of the upper corners of 
the apron a piece of webbing is sewed in between the 
thicknesses of the muslin, and these pieces are fastened 
to the buckles at the ends of the upper cross-piece. 
Between the top and bottom straps, two or three others 
are sewed in along each side; all of these on one side 
are provided with buckles, to receive those from the 
other side when fastened around the patient and the 
brace. 

When the disease is at or above the ninth dorsal ver- 
tebra, a head-support is used of the same form as that 
described in connection with the Taylor brace. With 
disease in the cervical spine a band may be riveted to 
the upper ends of the occipital rests and thence buckled 
around the forehead. When there is much rotary or 
lateral deformity in connection with cervical disease a 
ball-pivot may be used in place of the ordinary pivot, 
but this adds considerably to the expense, and it readily 
gets out of order. Under such conditions^it is usually 
better to reduce the rotary or lateral deformity by hori- 
zontal traction and use the ordinary pivot, or in place 



95 




Fig. 60.— The Thomas collar. 




Fig. 61.— The Thomas collar. 

of this brace the Thomas collar hereafter to be de- 
scribed. 

To measure for a spine-brace of this kind it is neces- 
sary to transfer to strong paper a tracing of the spine 
taken with a lead 
or block-tin tape, 
and upon this 
should be marked 
the length of the 
hip-band, the loca- 
tion of the pad- 
plates, the cross- 
pieces and the 
shoulder-pieces. To 
an instrument- 
maker unfamiliar 
with the work the 
sizes of steel to be 
used should be spe- 
cified and the pat- 
tern for the apron 
drawn. 

The Thomas col- fig. 62.— The Thomas collar applied. 




96 

lar, for use in disease of the cervical portion of the 
spine, is made by cutting from a piece of sheet-metal, 
steel, iron, aluminum, zinc, or tin, a piece straight on 
one side and convex on the other, long enough to some- 
what more than encircle the neck; at the ends it 




Fig. 63. — Thomas' cuirass. 

should be wide enough to reach from the base of the 
neck to the base of the occiput, and in the middle 
wide enough to reach from the sternum to the chin. 
It is bent to roughly fit the neck ; then the edges are 
turned slightly out, and the whole is wrapped in felt 



97 

and covered with sheepskin. At the ends a buckle 
and strap are attached, or two rings, so that the collar 
may be securely fastened around the neck, resting on 
the chest and shoulders, and supporting the chin, jaw 
and occiput. This simple device is one of the most 
satisfactory of all methods for treating cervical caries. 




Fig. 64.— Sliuwiijg cuirass belore it is covered with leather. 



Treatment of Spondylitis with the Thomas Cuirass. — 
The treatment of Pott's disease by this appliance (Figs. 
63 to 67) is based upon the principle of immediate 



and complete immobilization of the diseased area by 
an apparatus applied in most cases to fit the deformity, 
without any effort then, or at any time, to correct the 
deformity by suspension, posture, and only very excep- 
tionally by leverage. The principle logically obtains 








[JLe.^ 




^^^^' 



Fig. 65.— View of Thomas' cuirass applied to the patient. 



from the theory that a diseased joint recovers quickest 
when subjected to immediate and complete immobili- 
zation, and receives injury from, and is delayed in its 
recovery by, each successful attempt at correction of 
the existing deformity. 



99 

The brace consists of an irregular-shaped frame of 
flat bar-iron forged into the required form, as shown in 
Fig. 64. At the bottom it reaches to the level of the. 
great trochanter; that is to say, it extends as low as 
the sitting posture will allow. Laterally it extends 
from the space posterior to the great trochanter on each 
side, and from there curves upward, passing to the 
outer side of the posterior superior spines of the ilium, 
thence inward to the immediate neighborhood of the 
spinal column in the dorso-lumbar region, from there 
curving somewhat outward toward the posterior bor- 
der of the axilla?, then upward and inward to the 
back of the shoulders, at such distance as not to inter- 
fere with the movements of the arms, till the root of 
the neck is reached, when the two sides join in a hori- 
zontal upper bar. The width and thickness of the 
bar-iron used will depend upon the size and weight of 
the patient, but for a child of from 4 to 8 years it 
should be f by ^ inch. In forging the frame it is 
made to lie flat with some accuracy upon the patient's 
back. This frame, being in one continuous piece and 
nowhere pierced with .holes, gives a great degree of 
rigidity for its weight. Under it is placed a piece of 
fairly rigid leather cut to the same shape as the frame, 
but extending beyond its margins as shown in Fig. 64. 
Again, under this is placed a sheet of saddler's felt 
extending a little beyond the borders of the leather 
piece. The felt and leather are sewed together, and 
to them are fastened the necessary straps and buckles. 
The whole is then covered with basil leather (Fig. 63). 
From the bottom of the brace a broad leather strap, 
lined with felt, buckles across the front of the patient, 
and secures the brace to the pelvis. At the lower 
lateral curves of the frame, on each side, a buckle faces 
downward to accommodate a perineal strap, which in 
front passes up to a buckle on the broad leather strap 



100 



just mentioned. Above, at the junction of the neck 
and shoulder, a buckle looks forward and, at the lower 





U 




Fig. 66.— Front view of Thomas' cuirass. 



border of the axilla, another looks laterally on either 
side ; these are for the shoulder-straps. The shoulder 



101 



and perineal straps are of felt covered with basil 
leather. From the middle of the brace on each side a 
strap of webbing two inches wide passes over the 
abdomen of the patient and buckles (Fig. 66). The 
position of this strap is changed with the necessities of 
the case, and at times a second strap is added. 

Should the deformity be an extensive one and the 
angle formed by the spines 
of the diseased vertebrae be 
acute, one or both of two 
procedures may be neces- 
sary. The leather between 
the frame and over the 
kyphosis may have to be 
split, so that no pressure is 
exercised over sharp pro- 
jecting bone ; or, in addi- 
tion, a bar of iron may be 
so placed over the pro- 
jection as to render the 
recumbent position easy 
(Fig. 67). 

In exceptional cases, 
when the superincumbent 
spine falls considerably 
forward, traction is made 
by the shoulder-straps to- 
ward the cuirass, which, in 
such cases, in order to^^«- ^^--^^^ ^^^^^' ^^^^^'^ ^^*^ 

' , bridge for use during recumbency 

allow of a pull, is not fitted -when the deformity is severe. 

accurately to the upper 

portion of the back. In lumbar disease, or when there 
is psoas-contraction, a leg-piece is added, ending close 
above the knee, to prevent movement of the limb and 
traction upon the vertebrae. 

One of us (R. J.) uses this support largely. It is 




102 



comparatively cheap and cleanly. It can be removed 
at intervals while the back is cleansed, and a sheet of 
cotton wadding inserted between the support and the 
skin. It need not be removed oftener than twice a 
week. This cleansing should always take place while 
the patient lies on his face, with arms outstretched 
above the head. The special value of this support con- 
sists in the length of the 
spine that it controls. It 
reaches the seventh cer- 
vical vertebra above, and 
by its action on the 
shoulders partly governs 
the upper dorsal vertebrae, 
while below it extends to 
the trochanteric regions 
and is there assisted by 
groin-straps. There is no 
undue pressure upon chest 
or muscles, and, with care, 
no danger of sores or ex- 
coriation. It is easily 
worn and is never uncom- 
fortable and in no way in- 
terferes with recumbency. 

FIG. 68.-Thomas' cuirass with leg-attach- ^^ ^rdcr to meaSUrC for 
ment for reducing hip-deformity, and the Splint the patient 
for treating hip-disease when co- ^ i i i i t • -j. 

existent with spine-disease. should be placed m a Sit- 

ting position upon the 
chair and the distance measured from the seventh cer- 
vical vertebra to the chair. The measuring tape should 
not follow the contour of the back, but take the direc- 
tion shown in the vertical dotted line (Fig. 69). In 
diseases high up, when the collar is required, it is well 
to cut out for the instrument-maker a pattern in brown 
paper something like the old-fashioned stock. Unless 




103 

this be^done it is very difficult to secure an accurate 
fit, as the position of the head and neck varies so much 
in different cases. When there is any doubt on the 
part of the surgeon as to his being able to measure 
properly for a collar it is well to order one filled with 
sawdust, which can be modified as to size and be 
molded so as to shape to suit the particular case. 



ytl^-Cervical 



Fig. 69.— Method of measuring for the Thomas cuirass. 

When the disease is in the upper dorsal region, a 
Thomas collar may be added and buckled (as shown in 
Fig. 64), or any of the head-rests and chin-pieces al- 
ready described, may be attached to the upper portion 
of the frame. 

The absence of holes, screws, and rivets renders' the 



104 

construction of this brace simpler than that of the 
Taylor brace or any of its modifications, and while the 
patient is confined to recumbency it will be found more 
comfortable. 

The operative measures for the treatment of spondy- 
litis include aspiration of abscesses, with or without 
antiseptic injection; simple incision and drainage; and 
incision followed by erasion, with flushing with hot 
water, the wound being closed by suture and no drain- 
age provided. Other operations attack the spinal 
column, either for the removal of necrosed bone or for 
erasion of the carious areas ; and laminectomy may be 
performed for the relief of pressure-paralysis. 

Simple aspiration, even when often repeated, has, as 
one might expect, not proved of much value. It rarely 
succeeds in completely withdrawing the abscess-con- 
tents in consequence of the caseous masses present, and 
is often followed by a rapid refilling of the sac. We 
sometimes see a single aspiration succeed in obliterating 
the abscess; but, more generally, even after repeated 
aspirations, it ultimately proves a failure. We often 
notice after aspiration a disappearance, sometimes last- 
ing for many weeks, of all swelling, and then slowly the 
cavity refills. This points an obvious moral to those 
who publish cases as cured by operation before allowing 
sufiO-cient time to elapse to render a fresh collection 
next to impossible. 

Aspiration, followed by the injection of antiseptic 
fluids, has been abandoned, as also has the injection ol 
iodoform-ether ; but the injection of iodoform-"emul- 
sion " (10% mixture of iodoform in olive-oil or glycerin) 
still finds favor with some general surgeons, and, in 
their hands, is reported to yield good results. The 
results, however, are less favorable with the large, 
tortuous and deeply-seated abscesses of spondylitis than 
with those at other joints. We have long since aban- 



105 



doned the use of this method of treatment, as always 
useless and at times harmful. 

Incision of an abscess is demanded when the patient 
suffers from septic symptoms, when the location of the 
abscess is such as to prevent effective mechanical 
restraint to the diseased area, and when the abscess 
threatens important structures. Incision for the relief 
of such an abscess may have to be made almost any- 
where. In cervical disease, behind the sterno-mastoid 
muscle ; in dorsal disease, by the side of the vertebrse ; 




Fig. 70. — Diagrammatic section through the middle of the neck, showing the 
attachment of the pre-vertebral fascia laterally to the carotid sheath, thus direct- 
ing pus into the posterior triangle of the neck in cervical caries. The fascia is 
attached above to the base of the skull ; below it becomes lost in the posterior 
mediastinum centrally, and passing over the brachial plexus at the root of the 
neck in front of the subclavian artery to be attached to the costocoracoid mem- 
brane. If pus descends, it may find its way into the axilla or the posterior medi- 
astinum, in addition to pointing in the pharynx and the posterior triangle of 
the neck. 

in lumbar disease, just outside the erector spinse, and 
in the case of psoas-abscess resulting from disease in 
any part of the spinal column, an opening may have to 
be made above or below Poupart's ligament, or even 
attack made from the lumbar region. The accompany- 
ing diagram shows the arrangement of the pre-vertebral 
fascia in the neck, and explains its attachments, which 



106 

have everything to do with the direction of pus in the 
cervical region. The incision for the relief of abscess 
in this neighborhood should be made at the pos- 
terior border of the sternomastoid, care being taken 
to avoid the division of the spinal accessory nerve 
(which leaves the sternomastoid at its middle). The 
structures are then drawn forward with a broad retrac- 
tor, when the transverse processes of the vertebrae will 




n^niB 



Fig. 71.— The lumbar incision. 

be easily felt. If the abscess is large, it will be seen 
bulging and can be easily opened (preferably by Hil- 
ton's method). The finger is introduced and diseased 
bone felt for, and, if loose or easily detachable, removed. 
This operation should be performed, however advanced 
a retro-pharyngeal abscess may appear. It is a mistake 
to incise through the pharynx, as drainage in any posi- 
tion of the body is thereby rendered difiicult and 
risky. 

Dorsal abscesses may be opened where they present. 



107 

In the lumbar region, the vertebrse can easily be 
reached by an incision along the outer border of the 
erector spinse, cutting through the posterior fasciae and 
origin of the transversalis. The middle sheath and 
origin are now divided, and the quadratus lumborum 
is exposed. This muscle is easily known by the direc- 
tion of its fibers, which pass upward and inward. The 
lumbar arteries cause no trouble, and the incision is 
kept as near to the middle line as the wound permits. 
By careful dissection arteries may be seen if present 
and they can be clamped before division. The anterior 




Fig. 72.— Direction of the lumbar incision. 

fascia of the transversalis origin is now seen, then 
divided, and the finger passed along the front by the 
transverse processes and toward the bodies. The abscess 
can be easily felt by the finger, and fluctuation made 
out by pressing on the abscess in the thigh or abdo- 
men from the front. The sides of the bodies can be 
made bare by a blunt dissecting tool or closed dissecting- 
forceps, and the exploration completed when sequestra 
may be removed. Thorough washing should be done. 
The abscess should be opened, and the cavity washed 
out, and scraped gently with the finger, or finger covered 
with gauze, when a slight general oozing of blood takes 
place but soon stops. The abscess should next be 



108 

washed out with hot aseptic solution, preferably of 
boric acid. It will be found that after the cleansing the 
chronic abscess-wall collapses much more readily. The 
edges of the abscess-wall may then either be stitched or 
not. Deep sutures should be used for the quadratus and 
erector spinse, and the superficial wound should then be 
closed. If this has been done carefully and thoroughly 
aseptically the whole cavity becomes obliterated by 
organization of blood-clot, which may fill the original 
abscess-cavity, now much collapsed. Before stitching 
has .commenced, firm pressure is applied by an assistant 
pressing forcibly with both fists, one in the groin, the 
other over the abdominal wall, corresponding to the 
psoas sheath. This pressure must be continued until a 
firm pad is placed where each fist pressed tightly. The 
pads are then fastened by a carefully applied spica- 
bandage covering well over the abdominal wall. The 
loin-operation was first described by Treves. 

A. E. Barker has reported cases in which he has suc- 
cessfully incised and flushed psoas-abscesses. He takes 
a case in which he presumes the bone-lesion to be 
stationary or healing, but in which a purulent collection 
is gathering. He makes a 2-inch incision through 
sound structures in the most dependent part of the 
swelling, after which a hollow gouge is inserted through 
the opening, and connected by piping with a reservoir 
of hot water at 105° to 110°. This reservoir (a three- 
gallon can) is raised up to 5 feet above the operating- 
table. The fundus of the abscess-cavity is by this 
means flushed, and the contents are washed away. The 
more solid caseous mass is dislodged by gently scraping 
with a scoop, until the soft lining membrane of the 
abscess is washed away. When the water runs out 
clear, the instrument is withdrawn, and all the water 
squeezed out. lodoform-emulsion is then injected into 
the cavity, and stitches applied through the skin, the 
surplus iodoform- emulsion being squeezed out before 



109 

the stitches are knotted ; the cavity is then closed with- 
out drainage. 

Laminectomy for the relief of pressure-paralysis has 
been advocated by Macewen, Horsley, Lane, Willard, 
White, Lloyd, and others. 

The patient lies in a prone position, and a pillow is 
placed under the lower ribs to produce a curve in the 
vertebral column, and an incision is made over the 
prominent spine long enough to admit of the free ex- 
posure of the laminae by retractors, when the erector 
spinse is cleaned from them. Transverse notches in 
the muscle will facilitate this and do no permanent 
injury, owing to the ankylosis of the vertebrae ; owing 
to the curve in the spine this muscle is often easily 
drawn aside. The laminse may be carefully sawed 
with a spinal saw, or cutters used specially for the pur- 
pose. The dura mater and cord are drawn to one side, 
and the tuberculous material at the back of the body 
gently scraped away. 

The results of this operation are not such as to 
encourage its employment in any but the most desperate 
cases. It has distinct dangers of its own in its imme- 
diate effect upon the patient, and deprives the spinal 
column of practically its only support, when the bodies 
are largely eaten away by disease. It certainly should 
never be employed when thorough and prolonged 
mechanical treatment has not been tried. It is ex- 
tremely rare to find Pott's paraplegia permanent, and 
from an experience that has been exceptionally large, 
we can recall only two or three such cases, although 
we have experience of many in which the paralysis 
has lasted considerably over a year, and in a few for 
several years. With the recently revived operation of 
forcibly straightening carious spines additional hope is 
held out in these cases, and no case should be subjected 
to a cutting operation until forcible straightening has 
been tried and proved a failure. 



SACRO-ILIAC DISEASE. 

Disease at the sacro-iliac articulation is of compara- 
tively rare occurrence. Existing apart from spondy- 
litis in the lower lumbar spine, it is of still rarer occur- 
rence, and the diagnosis is so obscure that there are 
surgeons, careful observers and of extended experience 
in joint-diseases, who aflQ.rm that they have never met 
with it. For the most part, and perhaps always, the 
disease is tuberculous, and is governed by the same 
laws of pathology, symptomatology, and treatment that 
govern articular tuberculosis elsewhere. 

Traumatism frequently appears to be the exciting 
cause, especially when the disease is found in young 
adults, but there can be no question that the disease 
occurs without any remembered injury, especially in 
those predisposed by heredity to tuberculous infection 
and rendered susceptible by debilitating diseases and 
the infectious diseases of childhood. 

The disease may commence in either of the bones 
that go to form the joint, or in the synovial tissue 
within the joint. The bones more frequently appear 
to be the seat of the infection than the synovial tissue 
— there being no true synovial sac at this joint, but on 
account of the peculiar relations of the bones and be- 
cause of the strength and thickness of the posterior 
ligaments and the absence of definite subjective symp- 
toms in an early case, the disease is rarely recognized 
before suppuration has occurred, and all of the struc- 
tures of the joint are involved. The disease may be of 
the so-called moist form and show early suppuration ; 
or of the dry form, and run its course without suppu- 
ration; or the dry form under certain circumstances 
may at any time become suppurative. 



Ill 



m 




M 



Van Hook, who has made a most careful study of 
the literature of the subject, believes that the dry, non- 
suppurative form rarely 
imperils life and that the 
prognosis is in every way 
good, but that in the sup- 
purative form the progno- 
sis is exceptionally bad. 
It appears to us, how- 
ever, that the symptoms 
detailed of many of the 
non - suppurative cases 
hardly warrant the diag- 
nosis of sacro-iliac tuber- 
culosis, and by that much 
detract from the weight 
that they would other- 
wise give to a favorable 
prognosis ; and that the 
fatal termination and 
consequently unfavorable 
prognosis of the suppu- 
rative cases have more 
frequently been due to 
the character of the oper- 
ative interference than to 
the nature of the affec- 
tion. 

There seems to us to 
be no good reason for 
believing that tuberculo- 
sis of the sacro-iliac ar- 
ticulation is governed in 
its fatalities by other laws 
than those governing the fatalities of tuberculosis of 
other joints, whilst our limited clinical experience of the 



'4 



• -*:?'}¥ 





Fig. 73. — Characteristic attitude of sacro- 
iliac disease. From a photograph loaned 
by Dr. S. L. McCurdy. 



112 

disease goes to confirm this view. As in spondylitis, 
deaths occur from tuberculous infection of other organs 
quite as frequently in the dry as in the moist form of 
the disease, provided there be no operative interference. 
Death from prolonged suppuration is exceedingly rare 
when tuberculous abscesses are subjected to the let-alone 
treatment, and rarer still is death from septic infection. 
On the other hand there can be no reasonable doubt 
that any operative interference increases the risk of 
general tuberculous infection: and, unless the opera- 
tion be strictly aseptic, and the prolonged subsequent 
dressings be kept so, the risk from septic infection of a 
large canity connected with carious bone is considerable. 
In a word, any oj^eration that fails to remove all tuber- 
culous material and to close the cavity by primary 
union without drainage, though demanded as a last 
resort, should be recognized as distinctly adding to the 
risks of the patient's life. The records of the cases 
observed show that fatal termination is usually due to 
septicemia, simultaneous or intercurrent tuberculosis 
elsewhere, or general miliary tuberculosis. 

The first symptom to appear is usually a peculiar 
attitude, a "listing " of the trunk toward the unaffected 
side, or, more properly speaking, a shifting of the hips 
toward the affected side; and as this progresses the spine 
assumes a long, sweeping curve, with the convexity to 
the sound side. Before the peculiar attitude has become 
sufficiently marked to cause comment, the patient usu- 
ally finds himself fatigued on comparatively sHght exer- 
tion, and has experienced difficulty in bending forward 
and rising up again. Ultimately, stooping is quite im- 
possible. The gait becomes of a shuffling character, and 
as the disease advances the patient usually is unable 
to walk at all. In the early stage there is generally 
no fiexion of the thigh, but, later on, this frequently 
appears and. with some degree of abduction or of ad- 



113 



duction of the limb, simulates hip-disease or psoas- 
contraction of lumbar spondylitis. The abduction 
causes an apparent lengthening of the limb ; the ad- 
duction an apparent shortening. The patient, stand- 
ing, rests the heel upon the 
floor, but places nearly all 
his weight upon the sound 
leg. 

The distant or referred 
pain, characteristic of tuber- 
culous arthritis elsewhere, 
is usually present here, but 
may be absent. It is more 
frequently found in this af- 
fection than in disease of 
the hip or spine ; if present, 
it is usually felt in the lower 
abdomen, but may be com- 
plained of anywhere along 
the front of the thigh and 
also along the area of distri- 
bution of the sciatic nerves. 

At first the swelling of 
the joint-structures is more 
easily made out by palpa- 
tion through the rectum, 
probably owing to the an- 
terior sacro-iliac ligament 
offering much less resist- 
ance than the powerful and 

- . , . . ,. , , Fig. 74.— Right sacro-iliac disease, 
thick posterior ligament, and Leg abducted and gluteo-femoral 

- -,. ^, „ . crease lowered and nearly effaced. 

the swelling, thereiore, is 

directed toward the interior of the pelvis. Sooner or 
later the external swelling appears and in most cases 
advances to true fluctuation, and the tuberculous ab- 
scess is present as a complication. Such an abscess 




114 



may extend in any direction ; upward in the multifidus 
spin^e, into the lumbar region, downward along the 

psoas muscle, or into the 
buttock, to the right or 
to the left, or directly 
inward, to open into 
the bowel. 

The direction in 
which the pus travels 
may be: (1) Through 
the anterior ligament, 
keeping outside the 
pelvic fascia; (a) fol- 
lowing the course of 
the sacral nerves and 
pyriformis out through 
the great sacro-sciatic 
foramen and forming 
an abscess under the 
gluteus maximus; (b) 
following the curve of 
the sacrum behind the 
rectum to point in the 
ischio-rectal fossa, caus- 
ing inflammation and 
adhesion of the rectum 
and ultimately bursting 
into it; (c) coursing 
under the lumbo-sacral 
ligament into the psoas 
muscle and thence to 
the thigh ; (d) or into the iliacus muscle and thence into 
the groin. (2) Through the back part of the joint into 
the multifidus spinse, creeping along this and pointing 
in the lumbar region or directly over the joint itself. 
Muscular atrophy of the muscles of the buttock and 




Fig. 75.— Right sacro-iliac disease. Leg ad 
ducted and gluteo-femoral crease raised. 



115 

thigh is uniformly present. Deep pressure over the 
articulation often causes pain before much, if any, swell- 
ing is noticeable, and pressing together or pulling apart 
the pelvic bones also induces pain. This pain appears 
to be due more to the motion imparted than to the 




Fig. 76. — Abscess in right sacro-iliac disease. 

direct pressure exerted. At times there is a tilting of 
the bones one upon the other, so as to form an oblique 
kyphosis, or a depression; or one bone may be elevated 
and the other depressed. Spasmodic contraction of the 
psoas muscle is a pretty constant symptom and may 



116 

be found early in the disease ; in consequence of this 
the thigh becomes somewhat flexed on the pelvis and 
rotated outward; hence the frequent confusion with 
hip-disease. Motion at the hip-joint may appear to be 
restricted in all directions, but if the pelvis be steadied 
and the manipulations be conducted with such gentle- 
ness as not to disturb the sacro-iliac joint, it will be 
found that, when the thigh is slightly flexed to relax 
the tension upon the psoas, all the hip-joint motions 
are normal except those that put the psoas on the 
stretch, namely, extension and inward rotation during 
extension. In the same way the contracted psoas 
muscle restricts the bending in the lumbar spine, and 
the resulting condition simulates lumbar spondylitis. 
Passive bending of the spine toward the afi"ected artic- 
ulation or forward when the patient is recumbent, if 
practised with great gentleness and with the pelvis 
steadied, will, by the freedom of movement, exclude 
spondylitis from the diagnosis. 

The difi'erential diagnosis is, for the most part, made 
from hip-disease and from spondylitis, and it can only 
be made by remembering that disease in any joint 
restricts not some but all of its normal movements to 
some extent. In some cases of sacro-iliac disease in 
which the muscular spasm and pain are intense, it may 
not at once be possible to differentiate, especially as the 
disease has been seen coincidently with hip-disease, 
and as it is more frequently found in conjunction with 
lumbar spondylitis than existing alone. The condition 
may be mistaken for sciatica, or for intrapelvic inflam-" 
mation, or for abscess in connection with old recurrent 
appendicitis, but a careful examination and a consider- 
ation of the history of the case should clear up these 
points. 

The mechanical treatment of sacro-iliac disease is 
not one of the most encouraging of orthopedic prob- 
lems. It consists in a more or less successful attempt 



117 



at immobilization, but it is found far less easy to im- 
mobilize this joint than the hip or the spine, and satis- 
factory immobilization by an ambulatory apparatus is 
practically out of the question. The ambulatory appara- 
tuses that have seemed most successful have aimed at the 
accomplishment of two 
things : Immobilization 
by circumferential com- 
pression by a broad girdle 
and limitation to volun- 
tary motion by a spinal 
apparatus that restricts 
forward bending. There 
is no question that motion 
in the lumbar spine is 
contraindicated and there 
should also be no ques- 
tion that motion at the 
hip-joint is also contra- 
indicated, but restriction 
of the latter has not been 
attempted by an ambu- 
latory apparatus, as it 
would prevent the pa- 
tient from sitting. The 
fact that the girdle, in a 
certain number of cases, 
relieves pain, which is 
not relieved, but too often 
aggravated, by traction, 
points very suggestively 
in the direction of the 
true and of the false 
principles of the treat- 
ment of all joint-disease, namely, that a force that 
tends to immobilize, even when associated with a force 
that crowds together the articular surfaces, relieves 




Fig. 77.— Patient in apparatus. Brace 
should be bandaged to the thighs just 
above the knees. 



118 

pain, whereas a force that tends to separate the joint- 
surfaces without immobilization fails to relieve, and 
often increases the suffering. 

The mechanical treatment that we employ is some 
one of the modifications of the Thomas double hip- 
splint. The main stems should be separated at such a 
distance as to pass to the outer side of the posterior 
superior spines of the ilia, and lateral wings should be 
attached to the stems to pass around the flank on either 
side. One of us (R. J.) is accustomed to use the form 
of splint depicted in Figs. 76 and 77, and the other 
(J. K) uses the same frame, but adds a broad sling of 
leather stretched from one stem to the other and reach- 
ing from the coccyx to the mid-lumbar region ; both of 
us bandage the thighs to the stems. This is not de- 
picted in the illustrations. The patient is to be kept 
continuously recumbent for so long as any active symp- 
toms remain ; after that he may be allowed to stand 
and to make such attempts at walking as his brace will 
permit ; but the hips must not be released, so that sit- 
ting is possible, until the surgeon is reasonably sure 
that he has fully recovered. 

Inasmuch as this disease usually appears in adult life 
and but rarely in children, and inasmuch as the joint is 
fairly accessible, we are of the opinion that as soon as 
suppuration occurs, operative measures looking to the 
removal of all tuberculous matter are to be considered, 
and that such measures are justifiable in a larger per- 
centage of cases than when disease attacks any of the 
other joints. It is of advantage to prevent, when possi- 
ble, intrapelvic burrowing, and this can be done without 
our having to reflect, as we are forced to in the case of 
the hip or the knee, upon an ankylosis that would be 
harmless, or a shortening of limb that cannot occur. 

The operative procedures are determined by the 
facts learned from palpation externally and by way of 
the rectum. If an abscess can be detected within the 



119 



pelvis, the incision is made directly down upon the 
ilium externally to this point, the bone trephined, 
the abscess-cavity gently and thoroughly cleansed, 
more bone removed, if necessary, with cutting-forceps 
or chisel, all cut bone-surface thoroughly seared with 
the actual cautery and the wound closed. If no point 
of fluctuation can be made out 
the incision is determined by 
the edema, or, in the absence 
of edema, by the tender point. 
The bone is trephined for a 
caseating center, and the sub- 
sequent steps of the operation 
are as have been indicated. 
Recently Dr. L. L. Mc Arthur 
has recommended an operation 
over the main articular portion 
of the joint in all instances as 
being the region likely to be 
chiefly diseased. The posterior 
inferior spine of the ilium and 
the sciatic notch are the guides, 
and that part of the ilium which 
goes to make up the anterior 
inferior portion of the joint is 
removed by saw and chisel. 
After any operative procedure 
the joint should be immobilized 
in the Thomas double hip- 
splint, and the patient confined 
to bed until all local tenderness has passed away. 

It is possible that there are more reasons to justify 
the use of the drainage-tube after operations upon this 
joint than upon others, but we believe that a second or 
several repetitions of the operation entail less risk than 
the insertion of the tube. 




iliac 



-Apparatus for sacro- 
A leather sling 
may be stretched between the 
bars from waist to hips. 



HIP-DISEASE. 

The term hip-disease is used for any chronic inflam- 
mation of the synovial membrane of the hip-joint, of 
the acetabulum, of the head, neck, or greater trochanter 
of the femur, or of the soft parts immediately sur- 
rounding these, which, if allowed to progress without 
treatment, would ultimately present the symptoms of a 
tuberculous arthritis. 



—a 







';:!: 



i 



Fig. 79. — From a case of severe coxitis in a boy six years old. Primary tuber- 
culous infection in the head of the femur, (a) Cheesy spot ; \hh) infection 
of surrounding medulla ; (c) extension into the shaft ; {d) compression- 
groove ■where the head of the femur rested on the acetabulum. (Cut taken 
from Krause.) 

The synonyms in common use are hip-joint disease, 
tuberculous arthritis of the hip, morbus coxae, and 
coxalgia. 

The causes of hip- disease are tuberculosis, usually 
acquired, but occasionally inherited, inherited syphilis, 



121 

injury from falls, blows, and probably from jumping 
and from sprains, the infectious diseases of childhood, 
and the various causes that tend to chronic inflamma- 
tion in and about bones and joints. But whatever the 
cause, it ultimately presents the symptoms characteristic 
of a tuberculous arthritis, and for all practical purjDOses 
may be regarded as such. 

The precise location of the pathologic lesion, as a rule, 
•can not be determined. From our knowledge of like 
pathologic processes in more superficial joints we are 
justified in assuming that the disease may begin in the 
synovial membrane, but the symptoms of a chronic 
synovitis at the hip-joint are very obscure, and a diag- 




FiG. 80. — Resected upper end of a femur of a girl five years old. Large cone- 
shaped subchondral focus with demarcation far advanced; articular carti- 
lage lifted up like a vesicle. This is unquestionably a secondary infarction 
focus. (Cut taken from Krause.) 

nosis is rarely made before the bone is invaded through 
"the early destruction of the cotyloid ligament. When 
the disease begins as an osteitis it is not possible to say 
whether the primary focus is in the head, neck, or 
greater trochanter of the femur, or in the acetabulum ; 
and in many instances it is not possible to say whether 
the disease is articular or periarticular. This uncer- 
tainty as to the precise location of the primary lesion 
renders early operative treatment ridiculous; without 
-any treatment all of the tissues of the joint ultimately 
become involved ; treated mechanically, many cases 



122 




Fig. 81. — Cone-shaped sequestrum abutting against the cartilage, which is perfor- 
ated (a) with numerous holes and tilted away from the whole head of the 
bone. (From Krause.) 

recover so completely that we are still in doubt as to 
the location of the primary lesions. In the children 
of syphilitics, in cases directly traceable to injury, and 
in those cases that follow the infectious diseases there 




Fig. 82.— (a) Epiphyseal cartilage of the femoral head; (&) cartilage of the 
greater trochanter; (c) a cheesey sequestrum at the lower surface of the 
neck which has infected the joint. The head has been partially destroyed 
and is covered with a layer of granulation-tissue. (Fi'om Krause.) 



123 



is almost an equal uncertainty as to the primary patho- 
genic 'process ; but from the practical standpoint of 
symptoms, prognosis, and treatment it is with a tuber- 
culous arthritis that we have to deal. 

Si/mptoms. — Almost invariably the first symptom 
noticed is a slight limp. This usually begins before- 
there has been any complaint of pain, and it re- 
mains until a cure has 
been effected, and not in- 
frequently it persists to 
the very end of life. In 
a few cases there may be 
one or more intervals of 
intermission during the 
early months of the dis- 
ease. The limp is due to 
the inability of the patient 
to fully extend the thigh 
on the pelvis more than to 
any sensitiveness of the 
joint to weight-bearing ; 
although in untreated 
cases, and in very many 
that are subjected to treat- 
ment, there comes a time 
when walking is difiicult 
or impossible from the 
sensitiveness of the joint 
and its inability to sus- 
tain the weight of the 
body. Nevertheless, the characteristic limp of hip- 
disease is not one of pain ; it is ra-tlier one of impaired 
function. 

As a rule, the patient very early in the disease be- 
comes restless in sleep, and may cry out without fully 
awaking. The cry is peculiar, and consists in a sudden,. 




Fig. 83. — Early stage of hip-disease^ 
Flexion of right leg without notice- 
able lateral deformity. 



124 



sharp, frightened scream, occurring during the first 
hours of sleep. These night-cries commonly precede 
and almost invariably accompany a period of pain. 
They have been considered as characteristic of osteitis, 

though there can be no doubt 
of the presence of osteitis in 
certain cases in which no 
night - cries are heard ; it is 
more probable that they are 
indicative of a rather rapid 
development of a tuberculous 
abscess under tension. The 
symptom is valuable in the 
early stage of the disease only 
as corroborative of other 
symptoms and as a hint to 
the prognosis of abscess. 

Pain is usually complained 
of at some time during the 
course of hip-disease, but the 
fact must not be lost sight of 
that it is rarely complained 
of until long after limping 
has appeared. It disappears 
months and often years be- 
fore the joint is cured; and 
patients with nonsuppura- 
tive, and at times with sup- 
purative hip - disease may 
Fig. 84.— Flexion-deformity, with- nevcr feel the least pain from 

out lateral deformity, showing < j? -i 

obliteration of the giuteo-femorai the Commencement 01 tne 
limping all through the 3 or 
4 years' course of the disease to a cure, resulting per- 
haps in a perfectly ankylosed joint. When pain is 
present it is usually complained of at the inner side of 
the anterior surface of the knee, but it may be felt in 




125 



any part of the hip or thigh ; like the night-cries it is 
corroborative rather than a diagnostic symptom. It is 
indicative of an osseous lesion, and, coming on or 
growing worse without assignable cause during the 
course of treatment, should be considered as pointing 
to the development of abscess. 

Inspection of a case of hip- 
disease, stripped for examina- 
tion, reveals flexion of the 
thigh on the pelvis with or 
without accompanying abduc- 
tion or adduction. Most cases 
present one or the other lateral 
deformity, but the rule is not 
invariable, and some cases run 
their course and go on to a 
great degree of flexion without 
either abduction or adduction. 

Abduction when present 
usually is found in the early 
stage of the disease, and has 
been looked upon as indicative 
of efi'usion into the joint, but 
of this we do not feel certain. 
We have observed abduction 
late in the disease and in pa- 
tients where we have never 
been able to make out fluctu- 
ation. The position of abduc- 
tion gives a false lengthening 
to the limb, and is the cause 
of the obliteration of the but- 
tock-fold. 

Adduction usually appears when the flexion defor- 
mity has progressed so far as 25° to 40°. It gives a 
false shortening to the limb and raises the buttock-fold^ 
making prominent the hip. 




Fig. 85.— Early stage of hip-dis- 
ease. Flexion and abduction 
deformity s h o w iin g false 
lengthening. 



126 

Outward rotation or eversion of the limb usually 
accompanies abduction, and inward rotation accom- 
panies adduction. Occasionally when there has been 
great destruction of the upper end of the femur, outward 
rotation will be found associated with adduction. The 
cause of the malpositions at the hip have not been 
absolutely determined ; but it would seem probable that 
the position of the tuberculous focus, together with the 




Fig. 86. — Disease of the right hip. Marked flexion and adduction deformity. 



attitude assumed by the patient, determines the mal- 
position. The patient assumes the attitude of greatest 
comfort, whether lying, sitting, or standing, and this 
strongly influences the deformity in the early stages of 
the affection. Later the malposition is determined by 
the unbalanced force existing between the opposing 
groups of muscles in their effort to immobilize the joint. 



127 

or between the muscular groups on the one hand and the 
mechanical device employed in the treatment of the 
disease on the other hand. 

Muscular shrinking, generally believed to be due to 
reflex influence, comes on early, is very constant, and 
may be regarded as a very valuable symptom. It has 
been claimed bv careful observers that this muscular 




Fig. 87.— Same patient as shown in Fig. 86, with flexion and adduction-deform- 
ity reduced. Also shows scar from hip-abscess ; also the Thomas hip-splint 
applied to the right leg and the high patten on the left shoe. 

atrophy is due solely to disuse, inasmuch as it bears 
no constant relation to any other factor involved ; but 
we have observed a patient who had limped for only 2 
weeks, who had suff'ered no pain, and had not ceased 
from his usual avocations, whose afl"ected thigh meas- 
ured one inch less in circumference than the opposite 
thigh, a difference which went on increasing at a less, 



128 

but at an unusually rapid, rate during the succeeding 
fortnight before the application of apparatus. The fact 
that we do not know the relative sizes of the thighs 
before the limping commenced, renders the case of na 
positive value in controversial argument, but we are- 




Fig. 88.— Disease of left hip. Marked flexion, adduction, and outward rotation. 

much inclined to believe that there is present in these 
cases a shrinking of the muscular masses over and 
above that due to disuse and to the constricting effects 
of the dressings used. The muscular shrinking affects 
the thigh first, later the buttock, still later the calf, and 



129 



in some instances the whole limb. The symptom is so 
constant that it may be regarded as of very great diag- 
nostic value. We have, however, seen one case in 
which there was no muscular shrinking, but the thigh 




Fig. 89.— Same patient as shown in Fig. 88, with deformity reduced. Shows 
Thomas hip-splint with left wing of chest-band drawn higher than the right. 

was actually larger than the other throughout the entire 
course of the disease, which never presented any evi- 
dences of a suppurative process. 

Shortening may be either actual or practical, true or 



130 

false. True shortening is due either to arrested growth, 
to actual bone-destruction, or to partial or complete 
displacement of the head of the femur from the ace- 
tabulum. None of these conditions are found early in 
the disease, when a false lengthening is often present ; 
but an accurate record should be kept, for in this way 
the ultimate length of the limb can best be prognosti- 
cated. The true shortening is found by measuring 
from the anterior superior spine of the ilium to the 
inner malleolus on each side when the limbs are in like 
relations to the median line of the body. Practical, or 
false, shortening is due to adduction or flexion, or both. 
The false shortening is found by measuring from the 
umbilicus to the malleoli when the limbs lie side by side. 
It is from the relation of the actual to the practical 
shortening that the degree of adduction is calculated ; 
and the relation of the true to the false lengthening 
enables us to find the degree of abduction. A limb 
may be really shortened, but by being abducted be 
apparently lengthened. 

LOVETT'S TABLE. 



Distance Between Anterior Superior Spines in Inches. 
33^4 43^5 51^6 6>^ 7 7.1^8 8>^ 9 91^1011 12 13 









S» IH 

o S [2 



go 40 40 30 30 2° 2° 2° 2° 2° 2° 2° 2° 1° 1° 1° 1° 1° 
655444444433332 
10 88776655544433 
13 11 10 998777666554 
16 14 13 12 11 10 9 9 8 8 7 7 7 6 6 
19 17 15 14 13 12 12 11 10 10 9 9 8 7 7 
23 20 18 17 15 14 13 13 12 11 10 10 9 8 8 
26 23 21 19 18 16 15 14 14 13 12 12 10 10 9 
30 26 24 21 20 19 17 16 15 14 14 13 12 11 10 
34 29 27 24 22 21 19 18 17 16 15 14 13 12 11 
38 32 29 27 25 23 21 20 19 18 17 16 14 13 12 
42 35 32 29 27 25 23 22 21 19 18 18 16 14 13 
... 39 36 32 30 27 26 25 22 21 20 19 17 15 14 

40 35 33 30 28 26 24 23 22 21 19 17 16 

,S8 35 32 30 28 26 25 23 22 20 18 17 

42 38 35 32 30 28 26 25 23 21 19 18 



10 


8 


7 


14 


12 


11 


19 


17 


14 


25 


21 


18 


30 


25 


22 


36 


30 


26 


42 


35 


30 




40 


34 



The diff'erence between the real and apparent lengths 
of the limbs having been ascertained, we measure the 



131 

distances between the anterior superior spines of the 
ilia, and then by Lovett's table compute the degree of 
abduction or adduction. If the line which represents 
the amount of difference in inches between the real and 
apparent shortening is followed until it intersects the 
line which represents the pelvic breadth, the angle of 
deformity will be found in degrees, where they meet. 
If the practical shortening is greater than the real 




Fig. 90.— Same patient as shown in Figs. 88 and 89, cured with normal range 
of motion. 

shortening, the diseased leg is adducted ; it less than 
the real shortening, it is abducted. Take an example : 
Length (from anterior superior spine) of right leg, 23 ; 
left leg, 22^ ; length (from umbilicus) of right leg, 25 ; 
left leg, 23 ; real shortening, J an inch ; apparent shorten- 
ing, 2 inches ; difference between real and practical 
shortening, Ih inches ; pelvic measurement, 7 inches. 



132 

If we follow the line for IJ inches until it intersects 
the line for pelvic breadth of 7 inches, and we find 12° 
to be the angle of deformity, as the practical shortening 
is greater than the real, it is 12° of abduction of the 
left leg. 




Fig. 91. — Disease of left hip. Untreated case. Flexion adduction, outward 
rotation, and great shortening. 

The angle of flexion may be estimated in the follow- 
ing manner: The patient lies on his back on a table; 
the surgeon lifts the limb until the lordosis disappears 
and the pelvis lies in normal relation to the trunk ; he 



then measures from the table along the thigh, following 
the line of the femur, for any distance, and from there 
drops a vertical line to the table, noting the length of 
both these lines. The decimal fraction obtained by 
dividing the length of the vertical line by the length of 
the line measured along the limb will give the sine of 
the angle formed by the oblique line and the table. 
By consulting a book of mathematical tables the angle 
is found. Kingsley measures a constant length of 24 
inches along the thigh, and publishes a table showing 
the angle corresponding to the length of each vertical 
line from 1 to 24 inches. 



KINGSLEY'S TABLE. 



In. 


Deg. 


In. 


Bes. 


In. 


Deg. 


In. 


Deg. 


0.5 


1 


6.0 


16 


12.5 


31 


18.5 


50 


1.0 


2 


7.0 


17 


13.0 


33 


19.0 


52 


1.5 





7.5 


19 


13.5 


31 


19.5 


54 


2.0 


4 


8 


20 


14.0 


36 


20.0 


56 


2.5 


6 


8.5 


21 


14.5 


, 37 


20.5 


58 


3.0 


7 


9.0 


22 


15.0 


39 


21.0 


60 


3.5 


9 


9.5 


24 


15.5 


40 


21.5 


63 


4.0 


10 


10.0 


25 


16.0 


42 


22.0 


67 


4.5 


11 


10.5 


27 


16.5 


43 


22.5 


70 


5.0 


12 


11.0 


28 


17.0 


45 


23.0 


75 


5.5 


14 


11.5 


29 


17.5 


47 


23.5 


80 


6.0 


15 12.0 


30 


18.0... 


48 


24.0 


90 



Actual lengthening of the diseased member rarely 
occurs, but w^e have observed it during the course of 
treatment by the long traction hip- splint. An accurate 
record of the angle of flexion and adduction, or abduc- 
tion, is of the greatest importance. Upon a change in 
this angle, and upon this change alone at times, de- 
pends the diagnosis of disease ; and upon it depends 
the diagnosis of a cure in all cases resulting in anky- 
losis. An ankylosed joint in which the angle of de- 
formity is changing is not a cured joint; such a joint 
is capable, under proper treatment, of gaining a still 
greater degree of usefulness. In a case destined to 
result in ankylosis a cure is not effected until the 
angle of deformity ceases to change. 



134 

The involuntary muscular spasm which restricts the 
range of motion at the joint is the most important 
symptom of joint-disease. It is the first symptom to 
appear and the last to disappear, and it is the only 
symptom upon which dependence can always be placed 
in making the diagnosis. It is believed to be of reflex 
character, and to be due to irritation of the nerves that 
supply the joint. It affects only the muscles that con- 




FiG. 92. — Flexion beyond a right angle ; sinuses in the usual place, 



trol the movements of the diseased joint, but it affects 
all of them. At times it is so slight that it can be 
recognized with certainty only by comparison with the 
healthy joint of the other side, and at other times it 
prevents all motion so completely that the joint ap- 
pears to be ankylosed. Upon this symptom depends 
the diagnosis of the disease and the differential diagno- 



135 

sis from affections which closely simulate the disease. 
Lack of normal extension and rotation is usually more 
noticeable in the first weeks of the disease than are 
restrictions to flexion and the lateral movements ; but 
a careful comparison between the movements possible 
at the two hip-joints will render the defect apparent to 
one who has become at all familiar with this peculiar 
symptom. To describe the sensation which this invol- 




FiG. 93. — Scar from old sinus; flexion-deformity reduced. 



untary muscular spasm imparts to the hand of the 
examiner is scarcely possible ; it is one of those things 
better learned from the patient than from the teacher. 
The restriction which involuntary muscular spasm gives 
to attempted passive motion is not the slowly elastic 
yielding of voluntary muscular opposition, nor the 
sudden dead stop of ligamentous or fibrous adhesions ; 



136 

nevertheless, it is a sudden and a positive stop, which, 
when once felt, will always be recognized. 

The diagnosis of hip-disease is rendered compara- 
tively easy by what is known as the Thomas flexion- 
test. This is founded upon our inability to extend an 
inflamed hip without producing lordosis. By lifting 
the knee of the sound limb until it touches the chest 
the pelvis is fixed and the spine is straightened. If 




Fig. 94. — Sho-ws flexion-deformity of diseased left hip when sound thigh is 
flexed on the bodv. 



there be hip-disease the patient is unable to extend the 
thigh on the diseased side and it remains at an angle. 
If disease is absent the leg can quite easily be made 
straight. Few surgeons seem to have observed that if 
we take any healthy subject and lay him flat upon a 
table or other hard plane we can easily pass our hand 
under the lumbar vertebrae, but if we ask the subject 



137 

to touch the table with his back he is able to obliterate 
the hollow without lifting his limbs. We have here, 
therefore, a very ready guide for the detection of de- 
formity. In no case of hip-disease is the patient able 
to straighten his spine until art has stepped in and 
corrected the flexion-deformity. 

The application of the flexion-test in the case of an 
infant requires considerable delicacy. A child 2 or 3 




Fig. 95.— Same patient shown in Fig 94 ; flexion-deformity of left hip reduced. 

years old is brought for examination. A vague history 
of irritability may be alone complained of, or pain may 
be occasioned when the child is washed. The surgeon 
is to find out in the first place whether there is an in- 
flamed joint, and if so, on which side. The child is 
gently put upon the table, while the surgeon, without 
exciting alarm, holds a knee in either hand. The 



138 

thighs are slowly flexed toward the chest, when it is 
observed that one easily yields to full flexion while the 
other becomes a little rigid. The stifi" hip is then 
gently allowed to fall while the sound one is fully 
flexed. It will then be perceived that the diseased 
limb remains at an angle and cannot be fully extended. 
Stress must be laid upon the necessity of not startling 
the child and of not using the slightest force ; while 




Fig. 96, — Testing the movements at the hip-joint. 

care must be taken first not to flex the pelvis upon the 
spine, and secondly, to conduct the examination upon 
an even, flat surface. Although this test is not abso- 
lutely diagnostic, if the hip be complained of, and pel- 
vic, vertebral, sacro-iliac and malignant disease be nega- 
tived, one can fairly infer the presence of coxitis. 
The complications of hip-disease are abscess, sponta- 



139 

neous dislocation and separation of the head of the 
femur from the neck. 

Abscesses occur in about half of all casesVhere treat- 
ment is not commenced very early. They may be pre- 
sent in any relation to the joint, but the most frequent 
position for the first abscess to appear is somewhat 
below and to the inner side of the anterior superior 
spine of the ilium. An abscess may appear early in 
the disease or at any time 
during its course. It is usu- 
ally ushered in by a period 
of pain, night-cries, and in- 
crease of deformity ; tiexion 
is always present, and ab- 
duction is frequently found 
when abscesses appear early ; 
adduction is more common 
when the abscess appears 




Fig. 97.— To measure the angle of flexion, the line A B should have followed the 
line of the femur instead of tlie lower extremity as a whole. 



late in the disease. During the treatment of hip-dis- 
ease any exacerbation of pain or tendency to deform- 
ity, unless there has been some well-recognized trau- 
matism, is suggestive of the formation of an abscess 
and warrants that prognosis. The first objective sign is 
a brawny feeling in front of the joint; this is, or it soon 
becomes, tender to pressure, ultimately it softens in the 
center and fluctuation may be made out. The area of 



140 

fluctuation extends, the extension being usually in the 
outward and downward direction, and at times fully 
two-thirds of the upper, outer and anterior portion of 
the thigh is occupied by the fluctuating tumor. The 
abscess, however, may appear posteriorly to the greater 
trochanter, or it may be first made out within the iliac 
fossa, where it has found its way through the acetabu- 
lum or through some of the natural openings of the 
pelvis ; from here it usually makes its way up over the 
brim of the pelvis, following much the same course as 
a psoas abscess, and on reaching the thigh occupies the 
anterior and inner aspect. Sometimes an anal abscess 




Fig. 



. — Shows the normal archinK of the spine in a healthy person, which can 
be voluntarily effaced, as shown in Fig. 99. 



is simulated, and after spontaneous opening the per- 
sistance of symptoms strongly suggests fistula in ano. 
Much care is required in differentiating it. 

The course of these abscesses in untreated cases is 
towards spontaneous opening and evacuation. Rarely 
is there any especial fever or other constitutional 
symptoms except such as may be attributed to the 
pain ; and pain is felt only while the abscess is intra- 
capsular or subperiosteal ; when once the pus escapes 
from the bone or joint the suffering ceases and almost 
invariably the general health of the patient improves. 



141 

In patients where the joint receives full protection 
these abscesses, even after they have attained a very 
considerable size, frequently disappear by gradual ab- 
sorption. 

Spontaneous dislocation, which occurs but rarely, 
may be due to distention of the joint or to destruction 
of the upper border of the acetabulum. These cases 
present the usual characteristics of a hip-dislocation, 
but the Rontgen picture will render the diagnosis 
certain. 

Separation of the head of the femur from the neck is 
in our experience of such rare occurrence that we are 
unwilling to suggest any certain symptoms as charac- 
teristic. 



f^Sx^ 




Fig. 100.— The diagnosis of hip-disease in an infant. Disease in left hip. Lack 
of perfect flexion. 

The differential diagnosis of hip-disease is mainly 
from lumbar spondylitis, sacro-iliac disease, hysterical 
hip, congenital dislocation, traumatic dislocation, frac- 
ture of the femoral neck, and coxa vara. 

In lumbar spondylitis the patient may walk with a 
limp because the thigh is held flexed, and motion is 
restricted in extension and in rotation during exten- 
sion ; motion is free in flexion and in rotation during 
flexion. In hip-disease the attitude may be the same, 
but action is restricted in all directions. 

From sacro-iliac disease hip-disease is excluded by 
the same symptoms. 



142 

The hysterical hip may or may not present deformity, 
but rarely in a regular way and commensurate with 
the other symptoms ; the rigidity is excessive, but 
more characteristic of voluntary effort than of invol- 
untary muscular spasm ; there are shifting superficial 
sensitive areas without evident cause ; position changes 
during sleep ; the limb can be carried through the full 
normal range of motion if a persistent effort be made 
-and the attention directed elsewhere ; and there is no 
muscular atrophy even when the limb has not been 
used for a long period. 

Unilateral congenital dislocation at the hip gives a 
-history of limping from the commencement of walking 




:FlG. 101.— The Thomas flexion-test position ; elbow hooked through the knee and 
forearm carried across the chest. The aftected limb can not be forced down 
upon the table. 

without pain or other disability ; there is shortening of 
the limb of from f to 2 inches when measured from the 
-anterior superior spine of the ilium to the inner malleo- 
lus, but no shortening when measured from the greater 
trochanter to the outer malleolus, and the greater tro- 
chanter is found to be as far above Nelaton's line as the 
shortening shown by the first measurement. Motion is 
somewhat restricted in extension, abduction and outward 
rotation, but there is no characteristic involuntary muscu- 
lar spasm. The head of the femur can usually be felt 
lying under the gluteal muscles on the dorsum of the 
ilium when the femur is rotated inward. The Ront- 



143 

gen picture makes the diagnosis conclusive. In hip- 
disease this amount of shortening would be associated 
with great, probably complete, rigidity to motion in 
all directions. 

A traumatic dislocation at the hip would give the 
history of injury, with immediate and continuous dis- 
ability, growing better, if anything, rather than growing 
worse; the thigh would be held flexed, adducted, and 
rotated inward; there would be restriction to motion in 
all directions, and sensitiveness on motion without the 
characteristic involuntary muscular spasm of hip-dis- 
ease. There is shortening from f to 2 inches. The 
head of the femur can usually be made out under the 




Fig. 102.— Tilting of the pelvis by extreme flexion, giving a false flexion to the 
right thigh in a healthy subject. 



gluteal muscles, and the Rontgen picture renders the 
diagnosis positive. 

Fracture of the neck of the femur, although a mis- 
fortune usually looked for only in those past middle 
age, does occasionally occur in children. There should 
be a history of injury with complete disability coming 
on either immediately if the fracture is complete, or 
within two or three weeks if the fracture is incomplete, 
the disability unchanging or slowly improving but 
never growing worse. There is shortening of J an inch 
or more, and this is all above the greater trochanter as 
in dislocation. The limb is usually slightly flexed. 



144 



somewhat adducted, and considerably rotated outward. 
The range of motion and the sensitiveness on motion 
depends upon the time since the injury and the 
amount of union that has taken place. There is no 
pain when the limb is at rest, and no tendency to an 
increase of the deformity. The Rontgen picture renders 
the diagnosis positive. 

Coxa vara comes on either during the period of in- 
fantile or of adolescent rickets. There is a considerable 
period, often covering many months, of gradual short- 
ening without other disability, unless there should be 




ni iNI|l!|ll!l|||l !lll!|!l|J!ll|| ll||[!!i!! ri llll !| l ll i l |''! l ll!il |! ' j||| ! |l l ^'|| i i|i))^ 



Fig. 103.— Abscess on the inner side of the thigh coming down from within 
the pelvis. 



some traumatism, when there may be some sensitive- 
ness and rigidity for a time. After the shortening has 
advanced to f of an inch or more there is restriction to 
abduction, and later on, to extension, and finally to all 
motions at the joint. The shortening is all above the 
greater trochanter, and this can be demonstrated as in 
fracture of the neck and in dislocations. The charac- 
teristic involuntary muscular spasm of hip-disease is 
wanting. The Rontgen picture will clear up a doubt- 
ful diagnosis. 



145 

Treatment of Hip-Disease. — The principles govern- 
ing the treatment of hip- disease are based upon a con- 
sideration of that joint both in health and disease. It 
is the function of a normal hip-joint to permit of mo- 
tion in several directions and to sustain the weight of 
the body, both during walking and while standing at 
rest, without injury to its structure. When a joint be- 
becomes diseased, these functions become restricted or 
abolished, motion is no longer possible, or possible to 
only a limited degree, and the joint refuses to sustain 
the superincumbent weight for any prolonged period. 





Fig, 104.— The Henry G. Davis hip- 
splint. Designed to give elastic 
traction ; to give protection dur- 
ing locomotion, and to allow " mo- 
tion without friction " at the hip- 
joint. 



Fig. 105.— An early pattern of the 
short Say re hip-splint, with single 
perineal band. 



If we study the clinical evidences presenting at a 
hip-joint as it passes from health to disease and back 
to health again, we find them to be somewhat as fol- 
lows : All the muscles whose function it is to move the 
thigh on the pelvis gradually become more and more 
rigid from involuntary muscular spasm until all motion 



146 



at the joint is abolished. The thigh becomes gradually 
flexed on the pelvis, and usually at first abducted ; 
later on, as flexion increases, it becomes adducted ; but 
in either case the position is such, that in walking the 
full weight is not thrown upon the diseased member 




Fig. 106— The Taylor splint. 



Fig. 107. — The Judson long traction 
hip-splint. 



for more than a brief time at each step, and prolonged 
weight-bearing, while standing at rest, is not possible. 
The joint becomes more and more sensitive to the 
vibration of locomotion, weight-bearing is no longer 
tolerated, and the patient takes to his bed. The leg in 



147 

any case assumes the position of greatest comfort, and 
the muscular spasm protects the joint, which by this 
nieans becomes locked. As the patient falls asleep the 
muscular spasm relaxes somewhat, and if the limb does 
not lie securely fixed, motion takes place at the joint, 
injury is inflicted, the patient screams with pain, and 
the muscles are again on guard. 

Long-continued malposition results in structural 
shortening of the tissues on the side of the flexion, and 
immobilization of the joint is then maintained with but 
little muscular efl'ort. When the joint has been free 
from motion and weight-bearing for a certain time the 
tenderness passes off, and the patient is able to move 
about his bed without suffering, and ultimately arises 
and walks, often bearing his whole weight upon the 
affected member without pain. Nevertheless, muscular 
spasm and rigidity are maintained for a very consider- 
able time. When the disease has terminated the spasm 
disappears, but the structural shortening of the soft 
parts remains and yields gradually to use during the 
subsequent months and years ; but if the disease has 
been of a severe type it always remains to some extent. 

The result of this cure by the natural process is 
usually a limb flexed and adducted with true or false 
shortening, and a joint which lacks the normal range 
of motion. These defects appear to be due to the pro- 
longed course of the disease, which hinders the growth 
of the limb and renders more rigid the shortened mus- 
cles ; to the position of deformity in which the leg rests 
while structural shortening takes place, giving rise to 
permanent flexion and adduction and to their result, 
false shortening, and finally to the exaggerated bone- 
erosion and consequent true shortening brought about 
by Nature's unaided imperfect immobilization and pro- 
tection. 

The efforts of Nature to effect a cure may be supple- 



148 

mented by art. The means which art adopts are: To 
protect from deformity, or, if it has already appeared, 
to correct it, and thus rob the muscular contracture of 
its deforming power; to immobilize the joint, and thus 
relieve the muscles from a state of spasm and subse- 
quent contracture ; to relieve pain and prevent the 
bone-destruction due to both attrition and pressure ; to 





Fig. 108. — The Judson perineal crutch, 
with suspender strap and wooden 
patten at the side. 



a:5i^ 



Fig. 109.— The long Sayre hip-splint 
showing action of abduction 

screw. 



relieve the joint from weight-bearing and the pressure 
arising therefrom ; and finally, to diminish all these by 
shortening the course of the disease. The all-essential 
element of treatment, beyond the correction of any ex- 
isting deformity, may be summed up in one word — 
rest. The ideal treatment would be perfect rest of the 



149 

joint from active and passive motion, from the jarring 
incident to all locomotion, and from intraarticular pres- 
sure due either to muscular spasm or to weight-bearing. 
Such an ideal treatment we do not think has ever been 
attained. 

The fathers in surgery treated hip-disease by rest in 
bed and by more or less successful attempts at immo- 
bilization. Decros, in the Gazette des Hopitaux, of June 
30, 1835, published a case of hip-disease in which trac- 
tion was employed. In 1839, J. H. James, of Exeter, 
Eng., presented at the Provincial Medical and Surgical 
Association, at Liverpool, a plan of immobilization for 
the treatment of fractures of the thigh by the use of 
traction in the axis of the shaft of the femur. In the 
same year William Harris, of Philadelphia, published a 
series of 4 cases of hip-disease in the Medical Examiner, 
January 19, treated by traction and countertraction, 
combined with Hagedorn's apparatus for fractured 
thigh. The first of these cases was treated 4 months 
after the publication of Decros' paper. The first port- 
able traction hip-splint was devised by Ferdinand 
Martin, and is illustrated in Bonnet's Therapeutics of 
Articular Disease, Paris, 1853. 

Following these, traction was used by various sur- 
geons with weight and puUy and other devices, as a 
means of immobilization in hip-disease. In 1859, 
Henry G. Davis, then a resident of New York City, 
presented a plan of treatment essentially difi'erent in 
principle from any that had been previously employed. 
It consisted of a mechanical device, intended to give elas- 
tic traction and counter- traction at the hip-joint, without 
restriction of the normal motions of that articulation, 
the attempt being to separate the articular surfaces and 
to thus obtain " motion without friction " at the joint. 
Another radical change in principle was that the appara- 
tus was to be employed while the patient walked, it 



150 



being expected to furnish ample protection to the joint 
from the traumatism of locomotion. These principles 
of an ambulatory apparatus, which permitted motion 
at the joint and protected it by elastic traction and 
counter-traction, were at once adopted by Dr. Lewis A. 
Say re, Dr. Charles Fayette Taylor, and others, and the 





Fig. 110.— The Shaflfer hip-splint. 



Fig. 111.— The Eidlon long traction 
hip-splint. 



treatment, which was believed to allow " motion with- 
out friction " became known as the " American method '^ 
of treatment. 

It is, perhaps, unnecessary to say that the principles 
upon which this treatment was based have been entirely 
abandoned by the profession. Traction obtained by a 



151 



mechanical device, known as the long traction hip- 
splint, is still used both during recumbency and during 
locomotion, but it is no longer used with the idea that 
'' motion without friction " is a mechanical possibility. 
Perhaps the best commentary upon the use of the long 
traction hip-splint is to be found in the fact that in the 
city of New York three of the veterans in the profession 




Fig. 112.— The Phelps splint. 



Fig. 113.— The Phelps splint applied. 



use practically the same splint in the same way for the 
accomplishment of three different ends, namely, Dr. 
Judson uses the splint for the fixation it gives; Dr. 
Sayre uses it for the protected motion which it permits, 
while Dr. Shaffer believes the beneficial effect chiefly 
rests in the traction which it exercises. 



152 

We would not be understood as denying that unin- 
terrupted inelastic traction is an effective, though by no 
means the most effective, agent for obtaining fixation 
during recumbency ; but traction applied by means of 
an apparatus upon which the patient walks is quite 




Fig. 114. 



-The Blanchard splint, for anteroposterior fixation, longitudinal 
traction and lateral traction. 



another matter. As was pointed out so long ago as 1879 
by the late Dr. Joseph C. Hutchinson, of Brooklyn, it 
increases the up-and-down motion, a motion that is 
quite possible in a disorganized hip-joint, with each step 



153 

taken. It is only necessary to observe a child walking 
upon a long traction-splint to recognize this fact. The 
splint is applied while the patient is recumbent, and is 
made to exert a traction-force of from 8 to 10 pounds ; 
the weight of the splint is from 4 to 8 pounds ; when 
the patient stands upon the healthy extremity and lifts 
the aflPected member and the splint the traction upon 
the joint must be from 12 to 16 pounds ; in taking the 
next step the splint is placed upon the ground and the 
«ound limb lifted, bringing the whole weight of the 
patient to bear upon the perineal supports ; they yield 
somewhat, the splint bends a little, and the traction- 




FiG. 115.— The Thomas hip-splint, fitted with shoulder straps. 

force is entirely relaxed, as is shown by the straps bag- 
ging at the ankle ; with the next step, when the splint 
is lifted from the ground, 15 pounds of traction is again 
in force. We have thus an alternate traction down- 
ward of 15 pounds and a relaxation giving full sway to 
the upward pull of muscles dominated by involuntary 
spasm. This push-and-pull or pumping action at the 
joint goes on with each step in walking, or at the rate 
of about 3,000 strokes an hour as the child runs about 
in his ordinary play. Looked at theoretically this 
method would appear to be a most effective means for 
destroying the joint, but as a matter of fact most of the 



154 

cases treated in this way do marvelously well. To be sure^ 
w^hen treated by a traction-splint of the usual pattern 
(Sayre, Taylor, or Judson), that does not rise above the 
pelvis, and, as Lovett long since pointed out, allows 
about 30° of anteroposterior motion, most of the cases 
recover with flexion and adduction deformity, and with 



both true and false shortening, and much rigidity 




Fig. 116. — Method of changing the line of pressure on the skin from the- 
Thomas hip-splint. 

When the long traction-splint is supplemented by a 
body-piece, as in the Ridlon and the Phelps splints, 
with no motion between body-piece, hip band, and ex- 
tension-bar, the splint becomes the most useful means 
for the correction and prevention of lateral deformity,, 
and is second only to the Thomas hip-splint for correc- 
tion and prevention of anteroposterior deformity. Trac. 



155 



tion, during recumbency, when combined with leverage 
is a most effective means for reducing deformity, and in 
certain sensitive cases during the development of 
abscess, is a very efficient aid in allaying muscular 
spasm, and reducing the paroxysms of pain. In other 
equally sensitive cases it is not well borne, and positively 
increases the suffering. In the majority of cases it is 
neither indicated nor contraindicated. In cases that 
are no longer particularly sensitive it may be used as a 




Fig, 117.— Method of lifting a patient in the Thomas hip-splint. 



walking-brace without apparently doing harm, despite 
the theoretic evidence to the contrary, in the vast 
majority of cases. In patients too young to be trusted 
with axillary crutches, it furnishes the safest protection 
which we have against weight-bearing. The splint is 
expensive, costing about four times as much as the 
Thomas splint, and it requires intelligent care on the 
part of the parents, and frequent attention on the part 
of the surgeon. 



156 

The long traction hip-splint of the Sayre, Taylor, or 
Judson pattern we do not use except during convales- 
cence. It does not, at best, readily overcome deformity ; 
it permits the development of a marked flexion with 
abduction, or adduction, in cases where no deformity 
at first existed; it does not prevent exacerbations of 
pain and the development of abscesses ; in a word, it 
does not immobilize the joint sufficiently to give the 
protection required during the active stage of the dis- 
ease. With the body-piece added, as in the Ridlon and 
the Phelps forms of the traction-splint, combined with 
rest in bed for a longer or shorter period, the splint 
proves an efficient means of treatment. 

As has already been said, traction is not essential to 
the successful treatment of the majority of diseased 
hips. All that is necessary may be obtained by the 
use of an apparatus of simple construction, of slight 
cost, easy of application, not readily misplaced, rarely 
requiring attention, and more efficient in reducing 
flexion deformity than the traction-splint. We refer to 
the Thomas hip-splint. 

Before the time of the late Hugh Owen Thomas, of 
Liverpool, Mr. Hilton used a somewhat similarly shaped 
splint for the reduction of deformity ; and since that 
time Blanchard, of Chicago, and others have used a 
somewhat similarly shaped splint. Most surgeons, how- 
ever, have lost sight of the essential principles of con- 
struction and of use of the Thomas splint. The essen- 
tial principle of construction is that it be made of soft 
iron of a thickness that cannot be bent by the patient, 
but can readily be bent and fitted by the wrenches of 
the surgeon. The essential principle in the treatment 
is that the brace be so applied that it absolutely pre- 
vents anteroposterior motion at the joint. Splints of 
this general pattern when made of steel cannot be accu- 
rately fitted because of their elasticity ; if made heavy 



157 

they cannot be bent even with the aid of wrenches ; if 
made light the vibration rendered possible by their 
springiness counteracts all the beneficial effects of im- 
mobilization. Splints that are curved to follow the out- 
line of the patient, like the Blanchard splint, lose much 
of their immobilizing force from lack of the greatest 
possible leverage. Lateral traction, as illustrated in the 
Blanchard splint, and in the Phelps traction-splint, ap- 
pears to us to be an absurdity. That the lateral traction 
exerted by these two splints is an added means of im- 
mobilization we will not deny ; but we do deny that 




Fig. 118. — Fixed traction in bed used in combination with the Thomas hip-splint. 



they act in any way to distract the head of the femur 
from the acetabulum ; and it appears to us that this 
fact should be self-evident to any orthopedist or to any 
anatomist. 

The Thomas hip-splint consists of a main stem, a 
chest band, a thigh band, and a calf band, and occa- 
sionally an abduction or adduction wing passing around 
the flank. The splint is constructed of the softest and 
toughest iron. Annealed steel is not the material to be 
used, inasmuch as sufficient rigidity cannot be obtained 
without rendering the parts too difficult to easily mould 
to the contour of the patient. 



158 

Most serious results accrue from making splints too 
light, and the following practical instructions may be 
useful : For an adult of about 6 feet the upright should 
measure IJ by J inch ; for an adult of about 5 feet 6 
inches the upright should measure 1|- by J- inch ; in a 
child of 10 the upright should measure f by ^ inch ; 
for a child of 5 the upright should measure i- by |- inch ; 
for an infant of 2 the upright should measure J by /y 
inch. 

The wings should be the same width, and of such 
thickness that they may be readily bent by hand. In 




A B 

Fig. 119. — Correct and incorrect outlines of Thomas splints. A, B, C, D, correct 
outline ; A, B, body portion ; B, C, hip portion ; C, D, leg portion. The two 
upper outlines are bent to follow the outlines of the patient to some extent; 
they lose all leverage and consequent etfectiveness by the dip at G and M. 

length the splint reaches from the lower angle of the 
scapula to the junction of the middle and lower 
third of the leg, passing down posteriorly to the 
hip-joint. In growing children it is customary to 
make that portion below the joint somewhat longer 
than that above, but nothing is gained in immobilization 
by making one part longer than the other, taking the 
hip-joint as the middle point. The upright stem is 
bent in two places, one opposite the fold of the buttock. 



159 

the other just above the joint, so that the leg-portion 
and body -portion follow parallel lines distant from each 
other from one-half to two inches, this distance depend- 
ing upon the size and stoutness of the patient. 

As a rule the stouter the patient the nearer do these 
parallel lines approach each other. In case the tro- 
chanter is enormously hypertrophied the buttock bend 
may be entirely dispensed with, and in that case the 
body and thigh portions of the upright form a straight 
line. The bends referred to should be rather rounded 
than angular, as may be seen in the illustration. The 
leg-portion from the fold of the buttock to the lower 
end is perfectly straight, as is the portion from the 




J^iG 120.— Showing method of twisting the main stem of the Thomas hip-splint. 
This splint is being twisted to tit the left side. 



bend opposite the joint to the upper end. The stem is 
usually twisted somewhat in its longitudinal axis, so that 
the body-portion lies slightly to the side and flat against 
the curved outline of the chest, while the leg-portion 
lies directly posterior to the middle line of the leg. 
The buttock bend lies between the greater trochanter 
and the ischial tuberosity. The twist varies according 
to certain conditions which will be hereafter referred to 
in describing the adjustment of the splint. The chest 
band is also made of flat bar iron which varies in 
width and thickness in proportion to the size of the 
patient. It should be long enough to encircle the chest 



160 

to within an inch or two. If the splint be made re- 
versible so that it may be applied to either leg, as is 
customary in hospital work, it is joined at its middle^ 
to the upper end of the stem, whereas, if it is to be 
used only for a certain individual case, it is joined from 
one to two inches to one side of its middle, so that one^ 
wing will be longer than the other. The longer wing 
encircles the chest opposite to the diseased side, its 
greater length being due to the greater distance it has 
to travel. The relative length of these wings may be 
determined by measuring from the lower angle of the^ 
scapula around each side to the front where it is in- 
tended that they should terminate. There is no special 
advantage in having these wings to end opposite each 
other, although it may make a somewhat neater-looking 
apparatus. The upper end of the main stem is forged 
flat and bent over the chest-band and the two are made 
fast by a single rivet. In each end of the chest-band 
a hole, three-quarters of an inch in diameter, is forged 
for the fastening of the shoulder-bandage, or, what is 
less convenient, holes are drilled for the attachment of 
a buckle and strap. The thigh band is made of flat 
iron, and, being placed on the surface of the main stem 
next to the patient, is joined to it by one rivet at a 
point about an inch below the lower bend. If the- 
splint is to be made reversible the wings of this band 
should be made of equal length ; if it is intended for 
one side only the inner wing should be made an inch 
or two longer than the outer. The calf band is also 
made of flat bar iron and is joined to the lower end of 
the stem by a single rivet in the same manner and with 
the same relative lengths of wings as the thigh band. 
When an adduction or abduction wing is required it is 
made from the same sized iron as the thigh band. This 
should be placed at such a point that it will pass 
around the flank midway between the crest of the 



161 

ilium and the ribs. This point is usually midway be- 
tween the buttock bend and the chest band. The wings 
are bent approximately to fit the imaginary patient, 
and the surface of the entire splint next the patient is 
lined with felt of one-fourth inch thickness. The whole 
is then covered with that kind of sheepskin known to 
the trade as basil leather or "tan sheep." This should 
be put on wet and snugly stitched into place, so that as 
it dries the shrinking will prevent any slipping upon 
the iron. The stitching of this leather is, of course, 
done on the surface of the splint away from the pa- 
tient , it may be done with the so-called ball stitch, or, 
what is more serviceable but less neat, the edges of the 
leather may be drawn together and sewed through and 
through after the manner of the harnessmaker with a 
double waxed end; the redundant portion of the 
leather is then trimmed off. 

The splint is applied while the patient rests upon his 
back, the wings upon the side away from the deformity 
being opened out sufficiently to slide the splint under 
the patient from the affected side without unnecessary 
jar or movement. When the stem rests in place, the 
leg-portion wdll be directly behind the middle line of 
the thigh and leg, the part between the bends directly 
at the back of the hip-joint, and the body-portion some- 
what to the outer side of this line, the whole lying flat 
against the chest, thigh, and leg. This fitting may be 
done approximately with the hands, but better by 
the aid of wrenches. The wings to the inner side of 
the leg and thigh and the wing of the chest band on the 
same side, namely, those on the side away from the 
articulation, are drawn more closely than those on 
the affected side. The reason for this is that the splint 
tends somewhat to the affected side of the patient and 
to draw the leg into abduction. 

Particular attention must be paid to the bending of 



162 

the body-wings. As the chest is not circular it m 
necessary that the body-wings should not be made cir- 
cular, else intolerable soreness will result. By closely 
examining Fig. 122, this arrangement will be seen. The 
part between A and B upon which the patient lies is but 
slightly curved and this allows the body to rest comfort- 
ably and travel easily towards the diseased side, B, 
which is of great advantage. Another very simple ex- 
pedient consists in making a small hole in the bandage- 
and passing it over the outer of the thigh wings and 
rolling it under the splint and thigh and around the- 





Fig. 121. — An adjustable abduction or 
adduction wing for a Thomas hip- 
splint. 



Fig. 122.— Showing the relations oi 
the bands of a Thomas hip-splint 
to the chest, thigh, and leg. 



limb, so that the appliance is pulled in the opposite 
direction to that which it tends to travel. 

When satisfactorily fitted a short piece of bandage is- 
wrapped around the splint and leg, pinned securely, 
and another wrapped around the thigh above the knee,. 
or, what serves in some cases more satisfactorily, a 
single piece is wrapped around the knee in the figure- 
of-eight fashion and pinned with a large pin directly 
through the covering at the back of the splint so that 
the bandage cannot slip upon the splint, and any ten- 
dency of the splint to slip downwards is avoided. 



163 

If the splint is found too large, or, as when the pa- 
tient grows, too small, it may be necessary to modify its 
length. This is quite simply done. If it is too large, 
draw the body- wings towards the abdomen ; if too 
short, draw them towards the neck. A strip of broad 
bandage is then looped around the upper end of the 
stem below the chest band, and, having been twisted 
two or three times so that the ends will separate high 
up on the back, each end is carried over a shoulder 
and brought down to the hole in the end of the chest- 
band like a pair of braces ; here each is tied securely, 
crossed to the hole of the opposite side and tied again, 
w^hen the ends are firmly knotted. The final knot 
should be secured either with a long pin driven through 
it and twisted at its end, or with a bit of adhesive 
plaster. 




Fig. 123.— Showing method of binding wings of chest-band upwards and down- 
wards, and the method of looping a bandage over the outer wing of the 
thigh band to oppose rotation. 

The splint should be applied without bending the 
main stem from the shape already described, if it is 
possible to force the leg at the knee reasonably near to 
the splint. The lumbar spine readily curves when 
there is flexion at the hip sufficiently to allow the limb 
to be brought down to the splint when there is as much 
deformity as fifty degrees ; but if the deformity be very 
great, as much perhaps as ninety degrees, it may be 
necessary to bend the splint just enough to get the limb 
into contact with it when the fullest possible lordosis 
has been obtained. In these cases the bending is done 
at the upper bend of the main stem directly at the back 
of the joint. In practice, however, this will rarely be 
found necessary, and it has its disadvantages. 



164 



If there exists any considerable degree of abduction, 
a wing should be attached as already directed, passing 
around the flank on the side opposite to the disease. 
If there be any considerable adduction the wing is 
attached at the same point, but passed around the 
flank on the side where the disease is located. Care 
should be taken to draw these wings well in between 
the ilium and ribs, since pressure is not tolerated over 




Fio. V2i. — ^hjw:.i ^ r;:~: ^:^e temporary lordosis produced in correcting extreme flexion 
deformity by anteroposterior leverage. 

these bony points. At other times the body-wings are 
drawn toward the position taken by abduction or ad- 
duction wings when one cannot conveniently procure 
the additional wings. In the case of the very poor 
the hip-splint is often supplied by one of the authors 
(R. J.) without padding or leather. Lead-foil plaster 
is alone placed around the body-wings and stem. I 



165 

the splint has been accurately fitted no sore or excoria- 
tion results. 

If it is desired to prevent the patient from walking, 
a strip of iron is screwed on to the lower end of the 
splint, bent to pass free of the heel, and carried 10 or 12 
inches below the foot, so that standing or walking is quite 
impossible. This piece is called a " nurse," and will 
be found, when children are restless, a safe precaution 
during the period of recumbency. If severe leverage 
be brought to bear over the buttock in order to reduce 
a marked and rigid deformity, care should be taken to 
shift the skin about twice a day where it presses with 
most force upon the stem, and to see that all parts 
about the hips are kept clean, dry, and well powdered, 
otherwise pressure-sores may result. 

If the splint has been bent to fit the deformity, it 
must be straightened as soon as possible, sufficient opiate 
being given to quiet the pain during the few hours or 
days of the reduction of the deformity. During this 
time the patient must of course be kept in bed, and 
recumbency should be maintained until all pain and 
intense muscular spasm have subsided. When the 
deformity has been reduced the leg should be scarcely 
interfered with, the splint should not be removed, mo- 
tion should not be tested, even the bandages at the 
knee should not be changed except they become slack 
or soiled. The most absolute quiet to the joint and to 
the patient must be enjoined, and the necessities of 
nature should be attended to by gently lifting both 
lower extremities and inserting the bed-pan. This can 
be done without causing pain in even the most sensi- 
tive joint. The good limb is placed gently across the 
diseased one, and the nurse lifts the patient by placing 
one hand under the splint just below the knee, while 
with the other she lifts the chest-band. When all 
pain, tenderness, and muscular spasm have been quies- 



166 




Fig. 125.— The Thomas splint, with Fig. 126.— Front view of the Thomas 
^^ band around the hips, used as an hip-splint with adduction wing. 

added means for immobilization 
{^ in certain sensitive cases. 



167 

<cent for some weeks, and when no sign of fluctuation 
-can be made out about the joint, the patient may be 
allowed to arise and get about on crutches, aided by a 
patten on the sound limb. The patten consists of an 
iron ring with two uprights, the ring resting on the 
ground and the uprights rising- from the front and 
back, reaching to the shoe and fastened to the heel and 
«ole. The ring is oval- shaped, and is made of square 
bar-iron not less than f-inch thick. It reaches from 
the ball of the foot to the middle of the heel, and its 
width is slightly more than that of the sole of the shoe. 
The uprights are of round bar-iron set at right angles 
to the plane of the oval ring, when viewed laterally, 
and slightly oblique when viewed anteroposteriorly, 
and should, at their lower ends, be welded to it; their 
upper ends are forged flat, pierced with three holes 
and bent forward. If the patten is to be attached to a 
thin-soled shoe it will be better to rivet these flattened 
ends to a metal plate shaped to fit the sole of the shoe 
and screwed to it. The height of the patten depends 
upon the size of the patient and should be from, 4 to 6 
inches, high enough to prevent the patient from reach- 
ing the ground with the toe of the affected side. This 
with the ordinary crutches completes the ordinary 
walking outfit. 

For the most perfect result the patient should be 
kept recumbent until all pain, tenderness and muscu- 
lar spasm have subsided. He may then walk about 
on crutches and patten until all the soft tissues about 
the joint are well atrophied, and all trace of the disease 
has disappeared. The patten may then be dispensed 
with and the crutches shortened, and in this manner 
he may go about for two or three months*. If there 
be no evident return of the disease the crutches may 
oow be thrown aside and the joint further tested by 
two or three months' use. All still going well, the 



168 




Fig. 127.— The Thomas hip-splint with Fig. 128.— The Thomas hip-splint witb 
the left chest wing drawn down to adduction wing, 

act as an adduction wing. 



169 

splint is cut off at the knee so as to permit flexion 
there, a band being attached at the lower end after the 
same manner as the calf-band. This short walking- 
splint having been worn for two or three months, and 
there being no return of the symptoms of the disease, 
the splint is removed at night for a month or two. If 
the joint remains well the splint is removed for certain 
hours during the day, and then altogether, and the 
joint finally tested for perfect cure. 

The joint should be imprisoned long after the appear- 
ance of the disease has gone and after all subjective 
symptoms have disappeared, for the sensations ex- 
perienced by a patient recovering from articular disease 
cannot be very reliable under the masking influence of 
a splint. The test comes on removal of restraint, and a 



^ 



Fig. 129.— The iron " nurse " that may be screwed to the 
bottom of a Thomas hip-splint. 

very critical time it is unless the surgeon has grasped 
the knowledge whereby such a test becomes reliable. 
No surgical textbook gives any allusion beyond vague 
generalities to the means of knowing the right moment 
to discard the treatment. There is no more danger of 
relapse in cured joint-disease than there is of disease in 
a healthy articulation. But if a joint be pronounced 
fit for use when the remnants of inflammation have not 
gone, it is easy to understand the very frequent refer- 
ences to relapse which meet us everywhere. The law 
may be again laid down: A joint is cured of disease 
when the range of motion does not diminish by use, or 
in those cases resulting in ankylosis a cure may be 
pronounced where the angle does not change after use. 
Plaster-of- Paris will be found a convenient expedient 
in the treatment of hip-disease, and for some general 
practitioners perhaps the most satisfactory method: 



^. 



170 

•throughout the entire course of the disease. When used 
it should be applied from the ankle to the axilla, and it 
should be made especially strong opposite the hip-joint. 
A seamless, skin- fitting, combination garment is the best 
lining for the plaster ; in the absence of this, the patient 
should be wrapped in bandages made from sheet- 
wadding. Bony points like the iliac spines should re- 
ceive extra thick protection, lest pressure- sores develop. 
Any existing deformity at the hip should be corrected 
in so far as it is possible ; and as the main existing de- 
formity is sure to be flexion it is often difficult to decide 
how best to place the patient to minimize this deform- 
ity while the patient is being wrapped in the plaster 
bandages. Bartow, of Buffalo, is accustomed to par- 
tially suspend the patient, as in the application of the 
plaster jacket by the usual method, to stand the foot ot 
the sound limb on a block so that the affected limb may 
dangle, this being steadied by an assistant who grasps 
the foot and makes slight downward traction. This we 
have found to be a very unsteady and trying position 
for young children, and to tend to swing the leg too far 
into abduction in all cases except those where adduc- 
tion deformity is a positive feature. We are accustomed 
to rest the patient's pelvis upon a small support, raise 
his shoulders upon a pillow, and while traction is made 
from the foot by one assistant and from the shoulders 
by another, to apply the splint. In the few cases where 
traction upon the limb adds to the relief of the patient, 
we first put on a plaster stocking, and when it has set, 
continue the splint on upwards from this, taking care 
to carry it far up against the perineum, which has been 
previously protected by a broad strip Of felt. In this 
way the traction exerted by the assistant is maintained 
"to a great extent. The part of the splint opposite the 
joint may be strengthened by ribbons of wood or metal, 
•by strips of wire netting, or by carrying the layers of 



171 

the bandage directly up and down at the front, the side 
and the back, until the splint is an extra thickness at 
this weak place. A plaster splint should be left on so 
long as it is comfortable, unbroken, and fairly clean, for 
it cannot be changed without disturbing the diseased 
joint and usually doing it some harm. We rarely let a 




Fig. 130. — The Thomas hip-splint with abduction wing and " nurse" attached. 

patient up while wearing a plaster splint. If he is 
allowed up he should use crutches and a high patten as 
in the Thomas splint. 

All patients should be examined at the commence- 
ment of treatment for the purpose of diagnosis and rec- 
ord, and again at the close of treatment for a comparative 
record and for the diagnosis of a cure. In each instance 



Eioi 





Fig. 131.— Three views of the iron patten, used on the sound side, in connection 
with the Thomas hip-splint. 



the patient should, if it is practicable, be entirely 
stripped of all clothing, the attitude should be noted in 
standing, walking, and lying, the amount of. motion at 
the articulation compared with that of the sound side, 
the real and the false shortening, the abduction or ad- 
duction, the flexion and the atrophy. 



17: 




Fig. 132.— Front view of the short Fig. 133.— The short Thomas hip- 
Thomas hip-splint with adduction splint with adduction wing. Used 
wing. Used during convalescence. in convalescent cases. 



173 

It is our effort to encourage rather than otherwise the 
production of abduction in the cure of hip-disease. It 
■diminishes the amount of practical shortening caused 
by displacement, erosion, or arrest of growth. By 
recognizing this, we are sometimes able, where there is 
perhaps two inches actual shortening, to slant the pelvis 
suflB-ciently to render the apparent or practical measure- 
ments equal on either side. Adduction, although often 
inevitable, should be energetically combated. Mr. 
Thomas used to sling a bag of shot around the pelvis, 
the weight being attached to the side it was desired to 
depress. 

To render the pelvis fiat in a definite position during 
-examination it is customary for us to put the patient in 
what is known as Thomas' " flexion-test " position. 
This consists in flexion of the thigh of the sound side 
upon the trunk, so far that the elbow^ of that side can 
be hooked into the flexure at the knee and the forearm 
carried across the body. This gives a sufficiently defi- 
nite position to render measurement made at different 
times by the same or different surgeons comparatively 
accurate, although unless the surgeon be careful, flexion 
to the Thomas position in some cases tilts the pelvis 
upwards and renders the record of deformity not only 
that of the existing flexion but also that of the amount 
of the normal extension. 

These deformities may perhaps be more accurately 
measured with the goniometer, but the measurement 
with the tape is generally more convenient and is suffi- 
ciently accurate. The amount of muscular atrophy of 
both thigh and calf should also be recorded. This may 
be done by measuring the circumference of the limb at 
points similarly placed on both limbs. The degree to 
which motion is possible in the anteroposterior direc- 
tion may be ascertained in the same way as the deform- 
ities are measured. The deformity having been 



174 




Fig. 134.— The double Thomas hip- Fig. 135.— The double Thomas hip- 
splint, used in bilateral hip-dis- splint, with girdle added about 
ease, and in certain very sensitive the hips, 
cases of unilateral disease. 



175 

measured and recorded, the presence or absence ot 
involuntary muscular spasm, limiting the motion at 
the joint, should be tested. To make this test it is con- 
venient to first test the leg of the sound side. The 
pelvis is steadied by one hand, placed over the spines 
of the ilium, while the other grasps the leg just below 
the flexed knee; flexion, abduction, adduction, and 
rotation are then tested. The afi^ected limb is then 
tested in the same manner. In timid patients or very 
sensitive joints it may be as well to test rotation by 
rolling the leg from side to side as the patient lies upon 
the table, or the patient may sit with his legs dangling 
over the side of the table and the foot may be swung 
from side to side. The patient then is placed prone, 
and, if the degree of deformity will admit it, the leg is 
flexed on the thigh at a right angle, the ankle is grasped 
by one hand, the pelvis steadied by the other hand 
resting on the sacrum, rotation is tested by moving the 
foot from side to side, and extension is tested by lifting 
the whole limb from the table. The parts about the 
joint should be palpated for tenderness, induration and 
fluctuation. The presence and size of abscesses should 
be noted, the location of sinuses and their character, 
and the nature of the discharge. The advent of an 
abscess is usually first ushered in by increased pain, 
muscular spasm and increase of deformity. Tender- 
ness may often be made out on palpation, and sooner 
or later, induration or a boggy feeling is made mani- 
fest. This usually is first to be felt directly in front of 
the joint, although it may appear posterior to the greater 
trochanter, or in fact at any point in the neighborhood. 
As the abscess increases in size it usually extends down- 
ward and may come to spontaneous opening within 
a few weeks, or not until after many months. 

It does not appear to us that anything is to be gained, 
while often much may be lost, by early operative meas- 



176 




3FiG. 136.— The double Thomas hip- Fig. 137.— The Thomas hip-splint, with 
splint modified to relieve the left abduction wing and side bar to 

hip from pressure. restrain tendency to in-knee. 



177 . 

ures for hip-disease, provided there are no constitutional 
symptoms of septic infection. An abscess opened early 
invaritably conducts to carious bone, and generally to a 
joint extensively diseased. Rarely can all the tubercu- 
lous material be removed without a complete excision of 
the upper portion of the femur and of the acetabulum. 
Unless all diseased tissues are removed, a sinus is likely 




^^^^X:^-^^ 



Fig. 138.— The combiuatiou Rid Ion 
fixation-splint. This splint was 
first used in a case of hip-disease 
having a strong tendency to rota- 
tion of the limb. It may be used 
for hip-disease and knee-disease 
on the same side. 



Fig. 139.— Loop attached to a Thomas 
hip-splint for the treatment of hip- 
disease and knee-disease on the 
same side. 



to remain which may subject the patient to septic in- 
fection. An abscess left unopened for some months 
often descends a considerable distance and becomes cut 
off from the original focus. In such a case careful 
operative measures without drainage should result in 



178 

immediate closure and primary union, but it is not easy 
to tell when the abscess is no longer connected with a 
diseased bone or joint, and the surgeon who interferes 
takes a very serious responsibility. He should not, in 
our opinion, open such an abscess unless he can be 
reasonably sure of removing all tuberculous material, 
and of closing the wound without drainage. The use 
of a drainage-tube leads to the formation of a tubercu- 
lous sinus, which is exceedingly difficult to heal, far 
more difficult than a sinus resulting from spontaneous 
opening. When operative measures are undertaken we 
believe that the tuberculous tissues,whether sac of abscess, 
wall of sinus, synovial membrane, cartilage, or bone, 
should be removed by cutting with a knife or chisel^ 
instead of the scratching and scraping to which such 
tissues are usually subjected by the so-called sharp spoon. 
There can be no question that the risk of general in- 
fection is greater from a cutting operation than where 
none is done, but the risk is much increased by the scrap- 
ing process. In considering the treatment of these 
abscesses it should be remembered that a very consid- 
erable number of them, if left to themselves, the joint 
being put at complete rest, never go on to an opening,, 
but gradually dry up and disappear without any ap- 
parent ill effects to the health of the patient. 

If it was certain that every abscess would come ulti- 
mately to the surface, or if there were any reason for. 
believing that the health of the patient suffered from 
allowing them to remain unopened, or from their being 
reabsorbed, operative measures would be justified in all 
cases ; but as there is no way of knowing what is to be 
the course of any given abscess, we believe that the 
indications for operative interference should be made 
to depend solely upon the general health of the patient 
and that no abscess should be opened unless the patient's 
health be unquestionably suffering from the presence of 



179 




the diseased tissue. We 
would make the same rule 
regarding other operative 
procedures, such as the re- 
moval of the focus of disease 
within the bone, excision of 
the joint, and amputation. 
If any case in the recumb- 
ent posture should grow 
progressively worse under 
efficient immobilization of 
the joint, then the best ob- 
tainable hygienic operation 
for the removal of the dis- 
ease would be indicated ; 
but we have not seen such 




Fig. 140. — Front view of the Thomas 
hip splint Tvith addueting wing, 
and loop for the treatment of hip- 
disease and knee-disease on the 
same side. 



Fiit. 141.— Thomas' cuirass and double 
liip-splint combined ; for the treat- 
ment of spondylitis and double 
hip-disease in the same patient. 



180 

a case except where the disease had been allowed to go 
on to an exceedingly advanced stage without any treat- 
ment whatever. 

The preservation of the patient's life, then, we would 
make the only indication for an excision of the hip- 
joint, or for an amputation. The operation for excision, 
or for amputation, need not be described here, ^nce 
they are found in all works on general surgery, but if 
excision be performed, thorough mechanical treatment 
following the operation is indicated and should be the 
same as in the treatment of any unsound articulation. 
This after-treatment we think is often neglected by the 
general surgeon, and may account for some of the re- 
lapses which have been reported. The mechanical 
treatment of these cases, consisting of immobilization 
and protection to the joint, should be continued until 
every evidence of unsoundness has been absent for a 
very considerable time. The hip splint, used after an 
excision, should be supplemented by the addition of 
fixative traction, as is done in some cases of fracture of 
the upper portion of the femur. A strip of adhesive 
plaster is applied to each side of the limb from the 
upper portion of the thigh to the neighborhood of the 
calf-band of the splint, the lower ends of these strips are 
then carried to the foot of the bed, or around the wings 
of the ankle-band, so as to secure the necessary trac- 
tion, and fastened securely, and the splint is adjusted 
without the usual shoulder-straps. While the patient 
is lying in bed without shoulder-straps the splint 
tends to work downward sufficiently to overcome the 
miiscular contracture which would produce unnecessary 
shortening. 

At times old and neglected cases will be presented 
for treatment with a serious deformity, and the question 
arises as to whether any operative measures are de- 
manded. If muscular spasm be evident on attempting 



181 

motion at the joint even if there be no possible motion, or 
if an apparently sound joint possesses a certain degree 
of motion, the deformity can be corrected in a com- 
paratively short time by the leverage action of the 
splint; or the deformity may be corrected at once, or 
nearly so, by anesthetizing the patient and placing the 
limb in the best possible position. In these cases we 
do not recommend section of the tendons, fascia, or 
other contracted tissues, although there may be no very 
serious risk in their division. To this subject, however, 
we will return. We think it safer to divide the femur 
with the chisel either through the neck or in the neigh- 



m 



CD 



"t© 




Frc 142. — Wrenches for binding and twisting the Thomas splint. 

borhood of the lesser trochanter than to attempt a 
fracture by manipulation. The after-treatment of either 
of these operations is the same as indicated after an 
excision of the joint. The patient should remain in 
bed until union is sound, when the splint may be re- 
moved and he may remain in bed, an equal time, with- 
out immobilization, or in place of recumbency in cer- 
tain cases the splint may be cut off at the knee and the 
patient allowed to go about with splint and crutches 
without the patten, for a period equal to that which 
was required for the union of the bone. 

Cases occasionally appear with abscesses or sinuses so 
placed that pressure cannot be borne from the main 



182 

stem ; it is then customary to immobilize by the double 
hip-splint with a longer or shorter section of the main 
stem on the affected side removed. The double hip- 
splint, which is used in all cases of hip-disease affecting 
both joints at the same time, and in some cases of young 
children when the joint-sensitiveness in single hip- 
mischief is extreme, consists of the chest-band already 
described, from which two main stems pass at a point 
opposite the lower angle of each scapula downward pos- 
terior to each hip-joint and down the back of each 
limb, and separate at the bottom by a distance of from 
4 to 8 inches. The lower ends of the main stems are 
joined by a straight bar of iron, the, inner wings of the 
thigh-bands are usually omitted, and we generally add 




Fig. 143. — Wrench for binding the Thomas splint. Moditied from Moore's 
• triple-action ratchet drill. 



a lateral wing to each side. Upon this splint the patient 
can be moved from bed to a couch or to a carriage with 
very little inconvenience or pain. 

Cases of double hip-disease are not so very infrequent, 
occurring, perhaps in the ratio of 1 to 100 of single hip- 
disease. The disease rarely begins in both joints at the 
same time, and it occasionally develops in the second 
joint, while the patient is lying recumbent and protected 
from all traumatism during treatment of the first joint. 
Under these circumstances it frequently occurs that the 
joint last attacked recovers first, though not invariably 
with the greatest amount of motion. Partial or com- 
plete ankylosis of both hip-joints resulting from double 



1S> 



disease is not so very serious if the lumbar spine is sound 
and flexible, and provided the limbs are relatively 
in normal position. Patients are able to walk and to 
climb stairs, to sit, and to perform most of the ordinary 
movements of life, fairly well. The results of double 
hip-diseise, treated by the Thomas double hip-splint, 
appear to be somewhat 
better than the results of 
disease in single joints. The 
nature of the affection is 
such, that prolonged recum- 
bency is necessitated, and 
walking is impossible before 
recovery has become nearly 
complete. 

In hospital practice and 
among the very poor and 
ignorant, it will often be 
found impossible to keep 
the patients in bed with 
single hip-disease as long 
as we have indicated to be 
desirable, and it will also be 
found impossible in all 
young children and in many 
older ones using the Thomas 
hip-splint to compel the use 
of the crutches and high 
patten. Parents will permit 
these children to walk and 
bear their weight upon the 

diseased limb. As a matter of fact these cases do better 
than we might expect. We have observed many such, 
and find that some recover without flexion, rarely with 
adduction, and with very little, and sometimes no 
shortening. The number that have partially stiff joints 




Fig. 144.— Method of putting on the 
stocking when the hip is ankylosed. 



1S4 

is greater than among those where treatment has been 
carried out in accordance Avith correct theories. 

Now and again during the development of abscess a 
case will present so intense a degree of spasm of the 
adductor muscles that, if the patient remains fixed in 
the ordinary Thomas splint, knock-knee will result from 
adduction of the thigh, the lower portion of the leg 
being held by the lower part of the splint. This com- 
plication is prevented or corrected by passing a light 
bar of iron from the thigh band to the calf band, along 
the outer side of the leg, and bandaging the knee to this 
band as well as to the main stem. 

In cases in which disease of the knee-joint appears 
at the same time with disease at the hip, the knee may 
be immobilized by joining the knee and hip-splints 
together, or by adding to the hip-splint a light band of 
iron passing down each side of the leg and around 
somew^hat below the foot, and riveted to both the inner 
and outer wings of both the thigh and calf bands. 

In cases of spondylitis of the lumbar region, occur- 
ring at the same time as disease at the hip, the back 
may be protected by a stout sling of leather, passing 
from one main stem to the other of the double hip- 
splint, or the main stem with its thigh bands and calf 
bands may be attached to a spinal support. 



KNEE-JOINT DISEASE. 

Chronic disease at the knee-joint, commonly called 
white swelling, or tumor albus, is the same in character 
as chronic disease of the hip and of the spine. Tuber- 
culosis and syphilis in the parents predispose to its 
development in the child, as do the acute infectious 
diseases of childhood, and all those conditions which 
tend to a deterioration of the general health in adult 
life. Traumatism, however, plays a more important 
role in its causation than in disease at either the hip or 
the spine. The situation of the knee exposes it to 
frequent contusions, and no other joint except the 
ankle is more frequently subjected to sprains. 

The disease commences more frequently as an oste- 
itis than a synovitis, as is the case at the other joints ; 
nevertheless, the relative number of cases in which the 
disease commences in the synovial membrane is greater 
here than elsewhere, and apparently this can be ac- 
counted for only by the frequency with which this 
articulation is subjected to injury. From bruises and 
wrenchings some degree of simple synovitis results ; this 
is neglected because of the mildness of the symptoms, 
and in predisposed subjects it ultimately becomes the 
seat of tubercular infiltration. When the synovitis 
ceases to be simply traumatic and becomes tubercular 
w^e do not know ; it appears more than probable that 
there is no definite time, and that it depends very 
much upon the constitutional peculiarities of the indi- 
vidual. We have observed cases in which there was 
no positiv^e evidence of tuberculosis for many months 
after the onset of the simple inflammation, while in 
others tubercular synovitis commences without any 
remembered injury. It appears to us that, even in 



186 

those not predisposed to tuberculosis, a neglected sim- 
ple synovitis, should it fail to spontaneously recover, 
may ultimately become tubercular. Tubercular syno- 
vitis, whether arising from a neglected injury or as a 
primary infection, is usually diffused throughout the 




Fi«. 145.— Ivi,ic disease of four years' duration ■with^.iu ULariiieiit. This began 
as a synovitis, and only recently has shown flexion deformity and rigidity. 

entire lining of the joint ; only when secondary to an 
osseous focus have we seen it limited to a compara- 
tively small area. 

Tuberculous osteitis, here, as in other joints, may 



IS] 



begin as a primary or secondary focus. Its site is usu- 
ally in the epiphysis, more frequently than elsewhere 
in the inner condyle of the femur, next in frequency in 
the head of the tibia, and least frequently of all in the 
patella. The course of the osteitic tuberculosis is the 
same, in a general way, as elsewhere, and the joint- 
cavity usually becomes involved. 

The prognosis of disease at the knee-joint may be 
said to be good. The patient rarely succumbs to the 
disease unless the shaft of the femur or that of the 
tibia becomes involved. Un- 
treated, the leg becomes flexed 
on the thigh and somewhat ab- 
ducted and rotated outward, the 
flexion seldom exceeding 45°, 
and, if ankylosed at this angle 
after recovery, can be used in 
walking without crutch or cane. 
In severe cases, however, the tibia 
may become subluxated, and the 
outward rotation and knock-knee 
be so great that the limb is practi- 
cally useless. Tuberculous abscess 
occurs somewhat less frequently 
than at the hip, but when present 
is no bar to a orood result. Knee- ^^^- i46.— The usual appear- 

o ance of a case of knee-chsease. 

joint disease, untreated, results, as 

a rule, in ankylosis or greatly restricted motion, and 

that usually with considerable deformity. 

When disease at the knee is subjected to eflficient 
mechanical treatment the result is better as to deform- 
ity, function, and duration than is the case at any 
other of the larger joints. In no case, unless the dis- 
ease has been accompanied by great displacement for 
a long time, should there be recovery with deformity, 
and ankylosis should rarely remain ; and this holds 




188 

good even when great destruction has taken place, pro- 
vided there has been no subluxation backwards, or the 
rarer deformity of hyperextension of the tibia on the 
femur. 

At the knee-joint, more frequently than elsewhere, do 
we find the difference between synovitis and osteitis 
clearly defined in the early stages of the disease ; later 
on the dividing-line fades away, one condition merges 
into the other, and we have all of the positive symp- 
toms of both synovitis and osteitis. At this time an 
excision will reveal more or less complete tubercular 
infiltration of all the structures composing the joint. 




Fig. 147.— Knee-disease showing hyperextension deformity in place of the usual 
tiexion-deformity. These cases are very rare. 

It is not necessary to detail the symptoms of an 
acute traumatic synovitis ; with such a condition we 
have nothing to do, but, some weeks or months later, 
when the acute symptoms have disappeared, there 
may remain, in those predisposed to tuberculous affec- 
tions, and in those too impatient to give the time and 
attention necessary for a complete cure, a certain dis- 
ability. The joint may not be found to be quite as 
strong as formerly, it may tire more easily, there may 
be slight limping after a long walk or towards the end 
of a day's work. Examination reveals a slight increase 



189 

of the fluid normally in the joint; the bony outlines 
are less distinctly seen ; the patella may or may not 
float when the limb is fully extended and the synovial 
sac is compressed, both above and below ; there is a 
slight, springy resistance to full extension; there is 
usually some tenderness to pressure over the internal 
lateral ligament. Earely is there any complaint of 
pain, any local elevation of temperature, or any general 
tenderness. This condition may remain with little if 
any change, for may months, but ultimately the bony 
outlines become less and less distinct, circumferential 
measurement with the tape shows a considerable in- 
crease in the size of the joint, and the part assumes all 
the characteristics of a tubercular synovitis, and follows 
its usual course. 

A tuberculous synovitis may commence without any 
remembered injury to the joint. The first disability 
noticed is a slight limp after unusual fatigue, and an 
examination reveals the bony outlines obscured by a 
pulpy, semi-fluctuating distention of the joint. There 
is no pain, or restlessness in sleep ; no local heat or 
tenderness to palpation; no floating of the patella or 
true fluctuation; no atrophy of the muscular masses 
above and below the joint; there may or may not be 
increase in size of the joint by circumferential measure- 
ment, and motion is practically normal. Less fre- 
quently than in traumatic cases is there limitation to 
full extension, full flexion being the first motion re- 
stricted. The restriction is springy in character, and 
evidently due to the thickening of the joint-capsule, and 
a very different aff'air from the resistance occasioned 
by the involuntary muscular spasm which accompa- 
nies a tuberculous osteitis. These cases, as a rule, 
■ progress very slowly, but sooner or later the bone is 
invaded by the tuberculous growth, and the symptoms 
of an osteitis are added to those of a synovitis. Fio-. 



190 



145 illustrates such a case, in which swelling had been 
present for four years, and where, only within a few 
weeks, had there been stiffness at the joint or a ten- 
dency of the leg to become flexed, and in which as yet 
there had been no pain and no tenderness. Tubercu- 
lous degeneration may be considerable, and true fluc- 
tuation within the capsule may appear; the joint ma}' 



Fig. 14S.— Showing the bed-splint. 




Fig. 149.— The caliper splint. 



even rupture, and sinuses form, but this is rare before 
the bone becomes involved. More often some shrink- 
ing of the new tissue takes place as the bone becomes 
involved, and at times all swelling disappears, and the 
joint presents only the characteristics of tuberculous 
osteitis of the dry form. 



191 



Tuberculous osteitis invariably commences with a 
limp. This may be noticed for only a short time in 
the early part of the day, and days together may pass 
without any limping at all. After a time the child 
becomes restless in sleep and may scream out during 
the first hours of the night. Rarely is there any com- 
plaint of pain until much later in the disease. Exam- 
ination at this time reveals nothing abnormal in the 
appearance of the joint; the bony outlines are distinct, 
and no swelling can be seen or felt 
anywhere. There is, as a rule, some 
slight elevation of the local temper- 
ature, and there is often some bony 
point distinctly tender to firm pres- 
sure. More often than otherwise 
this tender point is on the inner and 
lower surface of the inner condyle of 
the femur. There is always present 
the involuntary muscular spasm, 
'characteristic of tuberculous osteitis, 
restricting to a greater or less extent 
the normal motions at the joint. 
The full degree of flexion is first 
lost, and soon the leg cannot be fully 
extended. Shrinking of the thigh 
and of the calf-muscles comes on 
early, and, with the involuntary 
muscular spasm, make the only con- 
stant and characteristic diagnostic 
sympt®ms. The degree of possible motion gradually 
diminishes, and false ankylosis results ; the leg is flexed 
on the thigh to an angle from 135° to 90°, some out- 
ward rotation and abduction of the leg on the thigh 
takes place, and walking becomes difficult. By this 
time, and in some cases much earlier, pain is com- 
plained of and may be very severe ; the condyles 




Fig. 150.— Theo^d form 
of splint with patten 
liottom no longer in 
use. 



192 

of the femur become broadened and thickened, but in 
some cases the head of the tibia is the part alone in- 
volved. The synovial membrane may be invaded by 
the tuberculous growth, or a tuberculous focus may 
rupture into the joint, and the whole membrane become 
at once infected. Now all the positive symptoms of 




Fig. 151.— The Thomas knee-spliut, 
showing the inner bar, B, placed 
farther to the front than the outer 
bar C ; A, is the lowest part of the 
ring ; upon this rests the tuber- 
osity of the ischium. 



Fig. 152— The ring of the Thomas 
knee-splint alter padding. 



tuberculous arthritis ma}^ be said to be present. Tu- 
berculous abscesses form in very many of the untreated 
cases, and opening spontaneously, may lead into the 
joint or only into bone-cavities. 

In rare cases the onset is sudden, and both bone and 



193 



synovial membrane appear to be affected at the same 
time. In these cases the symptoms are severe, the 
progress rapid, and few joints escape rupture if not 
opened by the surgeon. 





Fig. 153.— Showing the front view of 
the ring of 'the Thomas knee-splint. 




Fiw. 154.— Showing the back view of 
the ring of the Thomas knee- 
sr)lint. 



SH/tio 



'0£ 



THIGH 
Fig. 155.— Section outline of thigh, splint, and pressure pad. 

Multiple osseous foci are rarely found, but we have 
observed a focus at the inner condyle (which infected 
the synovial membrane by contiguity, and did not "'go 



w^ 



194 



on to the formation of a tuberculous abscess) coinci- 
dently present with a focus in the region of the epi- 
physeal line on the outer side of the bone, which lead 
on to liquefaction and spontaneous opening. 

Of the conditions which simulate tuberculous disease 
at the knee-joint none is so difficult to differentiate as 
the hysteric affection. It usually simulates the osteitic 
form of the disease, in which there is no change from 
the normal contour ; but in the shapely limb of a well- 
developed young woman, supplied with an abundance of 
subcutaneous fat, the pseud ofiuctuation of tuberculous 
synovitis in the early stage ma}^ be closely simulated. 




Fig. 156.— a, forward pressure of strap at the back of the ankle ; E, forward 
pressure of the padded ring at the upper part of the thigh ; C, backward 
pressure of the pad above the knee; F, adhesive plaster for downward 
traction ; B, the front of the padded ring. 

In these cases we have only the presence and exagger- 
ation of subjective symptoms to aid in making the 
diagnosis, and we cannot escape the knowledge that it 
is not impossible for true tuberculous disease to be 
present in an hysteric patient as well as in another. 
The simulation of tuberculous osteitis is even closer. 
The patient walks with a limp, complains of pain, the 
leg is somewhat flexed, the joint-motions are restricted, 
there is tenderness to pressure and increased heat 
about the joint, and the circumference of thigh and 



195 

calf may be less than those of the other side. Practi- 
cally, all the symptoms except the tuberculous abscess 
may be present, and only the trained eye of the neu- 
rologist, accustomed to recognize hysteric manifesta- 
tions, or the hand of the surgeon, practised to appre- 
ciate the resistance of the involuntary spasm of true 
bone-disease, may be able to make the diagnosis. On 
certainly one occasion a knee-joint has been laid open 
for excision and found perfectly healthy by a surgeon 
who disregarded the diagnosis of a neurologist and an 
orthopedist. As a rule, the hysteric joint is not accom- 
panied by muscular atrophy of the thigh and calf, and 




Fig. 157.— Showing the direction of supports and pressure pads 



the absence of this symptom should always be regarded 
as a significant fact. Muscular atrophy, however, does 
arise from disuse, and when present must not be taken 
as positively conclusive evidence in favor of a tubercu- 
lous inflammation of the bone ends. 

Acute traumatic synovitis should be readily excluded 
on account of the history, the heat and pain, and the 
fluidity of the contents of the greatly distended joint- 
capsule. 

The difi'erentiation from rheumatic inflammation 
should be readily made. The suddenness of the onset 



196 



U 



cE^^^ai 



Fig. 158.— The caliper splint. 
E, the ring around the 
ui^per part of the thigh ; 
A, pad for backward 
pressure ; B, bandage ; 
C, bandage ; F, leather 
sling for support at the 
back of the limb; D, a 
strip of bandage fasten- 
ing together the pressure- 
pads to prevent slipping 
and consequent loss of 
pressure. 



and the acuteness of the symp- 
toms are out of all proportion to 
that which ever occurs in tuber- 
culosis. 

The results of a gonorrheal or 
septic inflammation of a joint 
somewhat resemble certain cases 
of tuberculous disease, and, if the 
history of the case be concealed, 
may be confusing. In these cases, 
during the acute attack, the diag- 
nosis is readily made because of 
its acuteness ; when the acute 
symptoms have passed a certain 
amount of induration is present 
and is more dense to the touch 
than that present in tuberculous 
synovitis, and it is always accom- 
panied by restricted motion at 
the joint. The restriction is a 
mechanical one resulting from 
the inflammation, and in no way 
feels like that given by involun- 
tary muscular spasm. If there 
be doubt about the character of 
the resistance an anesthetic will 
settle the question. Rigidity due 
to muscular spasm will be lost ; 
that due to the results of an in- 
flammatory process will be mostly 
present. 

A spinal arthropathy, happen- 
ing to follow a traumatism, might 
puzzle one not accustomed to 
handle joints. In these cases the 
bone ends are increased in size 



19: 



without being tender to pressure or accompanied by 
pain ; the joint-distention is more fluid to the touch, and 
may contain semidetached masses, firm, and of consider- 
able size, the joint-mobility is great, soft crepitus may be 
heard or felt, and the patients almost invariably pre- 
sent some other indication of locomotor ataxia. 

As at other joints, the treatment of the disease may 
be mechanical or operative ; and, with the exception of 




Fig. 159.— Thomas' cutters and benders for changing the bed-splint to the 
caliper. 

the elbow, no joint is more favorably placed to give a 
rapid and satisfactory result whichever line of treat- 
ment be chosen. 

The principles of treatment are the same as else- 
where, namely, complete immobilization from the 
earliest possible moment until a cure has been effected, 
and relief from weight-bearing until convalescence is 
well established. When deformity is present it should 



198 

be rapidly corrected, since the healing process cannot 
go uninterruptedly forward while the angle of flexion 
is changing, and since recovery takes place more rapidly 
with the limb in full extension, and with a far better 




Fig. 160.— Rid Ion's cutter and bender Fig. 161. — Showing the counter of the 

for changing the bed-i^plint to the shoe cut away to re]ieve pressure 

caliper. This tool bends rods from on the tip of the heel. 
fij to f in. to a right angle. 

functional result. The deformity may be best corrected 
by the greatest continued-leverage force that can be 
tolerated, accompanied by fixative traction ; or the same 
result may be accomplished by careful manual correc- 



199 



tion under an anesthetic, followed by complete immo- 
bilization. 

Plaster of Paris, which has been used more exten- 
sively in disease at the knee than elsewhere, is a very 





Fig. 162. — Methods of boring the heel of the shoe when the caliper splint is 
used. 





Fig. 163. — Rear view of shoe 
with tube in the heel for 
using the caliper splint. 



Fig. 164.— Side view of shoe with heel slotted 
and tube inserted for use of the caliper 
splint. 



convenient method of treatment for the general practi- 
tioner, the general surgeon, and others unskilled in the 
use of mechanical devices. When used it should ex- 
tend from the ankle to the perineum, and in 



severe 



200 



cases, where it is difficult to control the tendency of the 
leg to flex on the thigh, it should extend from the toes 
to the waist. All splints that are shorter than the dis- 
tance from the foot to the pelvis lose enormously in 




Fig. 165.— Method of applying ] res- 
sure-pad to correct abduct ion de- 
formity. 




Fig. 166.— Showing the tool used to 
draw the inner bar away from the 
swollen knee. This form of splint 
is known as the bed-splint and 
shows the dimple at the bottom for 
tying the webbing strips from the 
adhesive plasters when traction 
is employed. 



effective immobilizing power, and those adjusted with 
innumerable screws and ratchets are expensive and of 



201 

little use. It is a pet delusion of many surgeons that 
interarticular pressure can be relieved by traction 
through adhesive plasters applied to the skin. These 
are applied on each side of the leg from the knee 
downwards for the traction force, and to the thigh from 
the knee upwards for the countertraction, the adjacent 
ends of the upper and lower plasters being apart but 
an inch or two. We have even seen them applied so 
that the upper and lower pieces overlapped, and this 
by an orthopedic surgeon in an orthopedic institution ; 
the absurdity of the arrangement, as a means of trac- 
tion on the bones, being ignored and even denied when 
pointed out, because the patient chanced to improve 
somewhat under that plan of treatment. Any traction- 
splint to be effective must extend to the tuberosity of 
the ischium for its point of resistance in countertrac- 
tion, and if used as a walking- splint, must extend 
below the foot. As a matter of fact none of the splints 
designed ^\iih the central idea of giving traction are so 
constructed. 

The splint, which we recommend, is known as the 
Thomas knee-splint, and is now used in only two forms; 
the bed-splint and the caliper. The form of the splint 
fitted with a patten at the bottom is no longer used- by 
us, and was not used for some years by the late Mr. 
Thomas in any but very exceptional cases. 

The bed-si^lint consists of a ring of round iron to 
which is welded a long loop of the same material, 
going some inches below the foot. The ring, in shape, 
is an irregular ovoid flattened in front, and drawn out 
at the posterior and inner outline of the thigh, and, as 
here observed, the inner rod of the loop, B, is joined 
more anteriorly than the outer rod, C. The ring slopes 
from without inward, and from before backward in such 
a way that the point A, upon which rests the tuber- 
osity of the ischium is the lowest part of the ring. The 



202 

angle formed by the plane of the ring and the inner bar 
is about 135°, and the anterior angle formed by the 
anteroposterior plane of the ring and the inner bar is 
about 145°. The thickness of the iron depends upon 
the weight of the patient and is from ^\ to f of an 
inch. 

In making the ring the end should be joined by 
welding, and the side bars of the long loop are joined 



,^ 



''U 




Fig. 167. — Showing the caliper splint adjusted in an old case of osteitis. 

to the ring in the same manner. Few surgical instru- 
ment-makers are good blacksmiths, and therefore find 
it easier to braze than to weld, but a brazed joint breaks 
on bending, while a welded joint holds fast. The lower 
end of the long loop is dimpled somewhat to receive 
and retain the straps from the adhesive plasters. The 
ring is padded with boiler felting to the thickness of 



203 

about half an inch on its outer portion, and from one to 
one and a half inches in thickness at the inner pos- 
terior portion upon which the tuberosity of the ischium 
is to rest, and then covered with basil leather, or tan 
sheepskin, put on wet, and sewed after the manner of 
the harnessmaker along the lower and outer border of 
the ring, where the seam will not chafe the patient. 
Two strips from three to four inches wide of the same 
leather are sewed by one end to one of the side bars, 
the other end being left free and of sufficient length to 
be drawn across to the opposite bar, and when sewed 
there to form a support for the back of the limb when 
the splint is applied ; one of these strips is to be placed 
at the back of the knee and the other at the back of the 
ankle. 

The splint is applied by slipping the ring on over the 
leg and pushing it w^ell up against the tuberosity of the 
ischium. If fixative traction is to be used strips of 
strong adhesive plaster, in width about one-fourth the 
circumference of the leg, and in length equal to the 
distance from the knee to the ankle, to the lower ends 
of which pieces of strong tape, webbing, or mus- 
lin bandage have been sewn, are applied to the outer 
and inner surlaces of the leg. If these pieces of ad- 
hesive plaster are supplied with narrow, oblique, lateral 
strips for winding around the leg, they will remain 
much longer attached to the skin. The plasters applied 
are held in place by an ordinary roller-bandage. The 
surgeon now grasps the patient's foot and pulls steadily 
downward, at the same time pushing the splint upward, 
and having straightened the limb as much as the patient 
will tolerate, ties the tape terminations of the adhesive 
plasters at the dimple at the lower end of the splint. A 
still better way consists in threading loops, attached 
to the end of the extension strips, with strings, and, 
after pulling, winding in spiral fashion the string on 



204 

either side round the bars of the splint until they meet 
below, where they are tied. By this expedient all pres- 
sure on the ankle is avoided, and the tension is longer 
maintained. 

The lower leather cross-strap is now placed at the 




Fio. IGS. — TLil'erfLilc-i; of the knee an'i ■■ 
caliper splint in position and the " haltt 



.'I tliiow. Showing the 
adjusted to the arm. 



back of the ankle, drawn snugly across, and sewed fast. 
The other leather strap is placed at the back of the 
knee, or at the back of some part of the thigh if the 
knee is too greatly flexed to rest upon it. drawn across 



2Uo 

to the opposite bar and sewed there. The knee is now 
pressed backward, straightening it as much as the 
patient will tolerate, and held there by a roller-bandage 
carried to and fro across the front of the limb around 
first one side-bar and then the other ; or a thick pad may 
be placed across the lower end of the thigh, well down 
upon the patella, and backward pressure made by a 
strong strip of bandage passed across from side to side 
and somewhat dowmward and tied to each side-bar by 
a half-hitch, and then carried across the pad and tied. 
After this the traction-tapes at the bottom are again 
tightened. The limb is left thus, if everything remains 
in place, for two or three days, when it can again be 
made straighter and the fastenings made tighter. In 
this way the limb is straightened. If the limb is to be 
straightened at once, the patient being anesthetized, it 
is better to apply the caliper form of the splint as the 
one giving better fixed-traction. This will now be de- 
scribed. 

The caliper- splint is made from the bed-splint by cut- 
ting oft' the lower end of the loop and bending an inch 
or more of side-bar inward at a right angle. The bed- 
splint is at first applied and pushed well up on the 
straightened limb, a point is marked on each side-bar 
half an inch below the sole and another an inch or an 
inch and a-half below this ; the side-bars are cut off" at 
the second point, and the bend is made at the point 
first marked. Fig. 160 shows the tool used in cutting off 
these bars, and the process of bending them. The 
shoe is cut at the heel, as shown in Fig. 161. This mutila- 
tion of the shoe is often necessary to prevent abrasion 
of the heel in walking. A hole is next bored through 
the heel of the shoe, or a slot is made by second hole 
crossing the first and a tube inserted. Into the hole, 
or tube, the bent ends of the side-bars are passed, the 
leather straps drawn fast and sewed, and the limb tied 









Fig. 169.— a bad case of knee-disease. 



£07 

or bandaged in place. If the knee is so swollen that the 
inner bar presses against it, this bar is curved with 
wrenches, or the tool is employed as shown in Fig. 166. 
When a joint has been straightened under an anesthetic, 
it should be left in the splint, without change of shoe, 
stocking, or bandages, until all pain and excessive ten- 
derness have passed off. In a word, the joint has been 
more or less sprained by the maneuver and must be 
treated with all the consideration which a sprain de- 
mands. 

The deformity corrected, the patient should be kept 
off his feet until the muscular spasm has subsided, 
when he may be allowed to walk about. If for any 
reason the patient has to be up before this time, he 




Fig. 170.— Au old case of knee-disease showing flexion, abduction and outward 
rotation, 

should use crutches or sticks and a thickened sole under 
the sound limb. 

The backward luxation of the tibia can be largely 
obviated by making the leather strip support the back 
of the head of the tibia, while extra backward pressure 
is made at the lower end of the femur. Instead of a 
bandage, the authors generally use two shields made of 
sheet iron and lined with felt, as seen in Fig, 158. 
This is much more effective and far simpler than the 
employment of a bandage. 

We employ this caliper- splint very exclusively, and, 
in the case of children particularly, we would impress 



208 

upon surgeons the necessity of making it sufficiently 
long so that the patient's heel is a good inch from the 
sole of the boot. In this way the ankle escapes a jar 
which were the splint shorter would surely be conveyed 
to the knee. 

The joint is more favorably situated than the hip for 
operative interference. Pulpy masses of tuberculous 
tissue may be injected with the iodoform mixture, 
tuberculous abscesses may be aspirated or aspirated and 
injected, as may the joint-cavity itself, or any collection 
of fluid may be laid open, washed out and the wound 
closed without drainage. Any of these procedures, if 
aseptically performed, may hasten the day of recovery ; 
but with either procedure septic infection may be in- 




FiG. 171. 



-The same case shown in Fig. 170 after a fair degree of correction of 
the deformity. 



troduced, and a serious injury inflicted. We wish to 
emphasize the belief that no one of these operative 
procedures is called for unless the' patient is already 
suffering from septic fever. 

As to the major operations, erasion has no longer a 
place ; it has no advantages over an excision in the 
final result ; motion is never regained, relapses are the 
rule, and deaths from tubercular infection are frequent. 
Excision as a time-saving measure in an adult case may 
be employed if the patient chooses, but in our opinion 
is in no other way justifiable. Any joint that can be 
cured by excision can also be cured by mechanical 
means without excision, and with a better ultimate 



209 

result. We. of course, refer to joints diseased and not 
to deformities remaining in joints no longer diseased. 
The result of an excision in an adult is a stiff, peg 
leg with from one to two inches shortening. This may- 
be preferred by the patient to a somewhat longer course 
of treatment and a movable joint, or to an amputation 
and an artificial limb ; but the evil result of the oper- 




FiG. 172.— An old osteitis showing flexion deformity and false ankylosis, but 
no swelling. 



ation in children does not end with the healing of the 
wound ; so long as the child continues to grow, deform- 
ity of shortening increases, and when adult life has 
been attained the limb may be from three to nine 
inches short, and prove practically a useless member. 
In children, then, we believe that excision of the knee- 
joint for disease is never justifiable. Any joint that can 



210 

not be cured without excision demands an amputation. 
For the correction of deformity in a cured joint several 
operative procedures may be employed. In false anky- 
losis, brisement force, followed by complete immobiliza- 
tion until the part has recovered from the injury done, 
is often demanded. In true ankylosis, excision, osteo- 
clasis, or osteotomy may be demanded according to the 
degree of deformity. Osteotomy is to be preferred if 
the subluxation be not too great, and if the irregular 
shape of the limb resulting from the operation be not 
objected to. In our opinion, osteoclasis, although counted 
a safer operation, is not so in these cases. Excision of 
a wedge-shaped piece including the upper end of the 
tibia, the lower end of the femur, and the patella with 
the redundant soft parts should be chosen when the 
deformity is very great, and when the neatest possible 
contour of the limb is an object in the result. The 
details of the operation are not demanded as they 
would be for an excision when disease is present, since 
the only direction necessary is to remove everything 
that is in the way of complete restoration to a straight 
line, and the only caution required is to remove enough 
to relieve all strain posteriorly, and all pressure be- 
tween the sawed ends of the bones. Clean surgery and 
closure of the wounds without drainage, and complete 
immobilization go without saying. 

The diagnosis of a cure of disease at the knee-joint 
is the same as at any other joint, namely, absence of 
pain, swelling, tenderness, muscular spasm, no increased 
restriction to the range of motion in joints where there 
is motion, and no progressive tendency to deformity in 
joints where there is no motion. 



ANKLE DISEASE AND TARSAL DLSEASE. 

The ankle-joint is more frequently sprained than the 
knee ; hence traumatism here plays a more important 
part in the etiology of chronic joint-disease than at any 
other joint. In all other respects disease at this joint 
is influenced by the same predisposing causes as else- 
where. Primary tuberculous osteitis is comparatively 
rare; while tuberculous synovitis is comparatively 
frequent. 

The symptoms of ankle-joint disease when following 
a neglected sprain present a continuance of the symp- 
toms due to the injury, namely, swelling about the 
malleoli and in front of the joint, more or less disability 
from restricted motion, and tenderness, and not infre- 
quently there is pain. The foot becomes extended, 
walking is more difficult, the swelling increases, the 
lower end of the tibia and fibula become thickened, the 
bony outlines of the malleoli are lost in a pulpy swell- 
ing, and ultimately one or more tuberculous abscesses 
form at one or both sides of the joint. Tuberculous 
synovitis commences with a limp ; soon there appears 
a pulpy swelling about one or both malleoli, the foot 
becomes extended and the normal motions are re- 
stricted, the swelling increases, and the part presents 
all the symptoms detailed above as developing upon a 
traumatic synovitis. 

In the osteitic form of disease, the first symptom is 
the limp, pain comes on earlier and is more severe, the 
foot becomes extended, and all motions may be abol- 
ished before any swelling can be made out. Sooner or 
later the synovial membrane becomes involved, and the 
symptoms of a tuberculous synovitis appear ; or a small 




Fig. 173. — A tuberculous ankle with sinus on the outer side. 



213 



spot of pulpy swelling may appear at one or the other 
side of the foot without involving the joint-capsule. 





Fig. 174.— The crab splint. 



Fig. 175.— The crab splint applied. 



As already indicated, this pulpy swelling, if left un- 
treated, almost invariably goes on to the formation of a 



214 

tuberculous abscess, which increases up to a certain 
size, and opens spontaneously. The usual tuberculous 
discharge persists for a longer or shorter time, granules 
and flakes of bone come away, and finally the swelling 
subsides, the sinuses close, motion at the articulation 
returns, and, with the exception of a few scars, the 
joint, in children, may be as good as ever. Permanent 
deformity and disability at the ankle-joint are com- 
paratively rare. 

Tarsal disease arises, as a rule, in the same way, and 
presents the same symptoms as indicated under the 
osteitic form of disease at the ankle-joint when the 
synovial membrane escapes. The differentiation be- 
tween osteitis of the bones forming the ankle-joint and 
those of the tarsus is made by the direction of the 
restricted motion. When the ankle-joint is diseased 
anteroposterior motion is restricted, and lateral motion 
is free ; when the tarsus is diseased the lateral motion 
is restricted, and the anteroposterior motion is free to 
gentle manipulation. In severe and advanced cases' 
both motions may be restricted, and it may be difficult 
to decide whether the rigidity is due to disease in both 
places, or to muscular shortening arising from the long 
continuance in one position. 

The differential diagnosis is mainly from sprains, and 
of these we have already spoken. We rarely see hys- 
teric affections of the ankle-joint, and the points of 
differential diagnosis from rheumatic and septic affec- 
tions are the same as in disease at the other joints, and 
need not be repeated. 

The principles of treatment are the same as else- 
where in joints of the lower extremities, and the me- 
chanical treatment of disease at the tarsus and in the 
ankle-joint are the same. If the foot is extended, it 
should be returned as rapidly as possible to a right 
angle with the leg, since in this position it recovers 



215 

most rapidly, and is most useful should any stiffness 
remain after the cure has been effected. Immobilization 
is maintained by the crab-splint, which in our hands is 
more convenient and more effective than plaster of 
Paris, though the plaster-splint, applied from the toes 
to the garter-line, serves a better purpose here than at 
any joint except the wrist. The crab-splint consists of 
a piece of sheet iron hollowed to fit the upper two- 
thirds of the posterior surface of the leg. To this is 
riveted a flat bar of iron, f x^^g-, or such size as will 
hold the part firmly, and it is bent to approximately 
follow the outline of the back of the ankle, and heel, 
and the middle of the sole of the foot. At the point 
where it passes around the bend of the heel is riveted 
a cross piece of iron reaching two- thirds around the 
ankle and of such thickness as can be bent by the 
hand ; and at the end of the main bar is riveted another 
piece of like metal long enough to nearly encircle the 
foot at that point. The whole may be japanned and 
applied over a thin layer of cotton, or it may be covered 
with leather without padding, and applied next to the 
skin. The splint is bent to grasp the foot as accurately 
as possible, and held in place by a strip of adhesive 
plaster and a roller-bandage. Young children who can 
be kept off their feet, and adults who can be trusted 
with axillary crutches, require no further appliance, 
but in others the knee-splint extending from 2 to 4 
inches below the foot with a patten bottom should be 
used. The splint is made from the bed-form of the 
knee- splint by cutting off the bottom of the long loop, 
and welding on at right angles an ovoid ring of flat bar 
ironf inch in diameter. The greater diameter of this 
ring should be from side to side, for if the greater 
diameter be from front to back the strain in walking is 
thereby, increased, and it may break from the side bars. 
The knee splint is supported by a webbing strap from 




Fig. 176. — The long protecting splint, used at times in ankle-disease. 



217 

the top ring passed over the shoulder of the opposite 
side. The limb is loosely held in this splint by a roller- 
bandage at the knee. 

The operative treatment of disease at the ankle and 
tarsus is justifiable when the disease progresses despite 
effective mechanical treatment and protection. ' A true 
excision of the joint should not be attempted. The 
tuberculous tissue alone should be removed by a cut- 
ting rather than a scraping instrument. If one is rea- 
sonably certain of having removed all the disease the 
wound should be dried and closed without medication 
or drainage. In case of a return of the necrotic process, 
or in cases where there is a reasonable doubt as to the 
removal of all diseased tissues, the wound should be 
left open and packed with gauze saturated with balsam 
of Peru. This we believe to be a better plan than the 
usual dressing of iodoform and rubber drainage-tube. 

The diagnosis of a cure consists in the absence of all 
symptoms, and increase of function by use. If anky- 
losis results, recovery is demonstrated by the fact that 
the angle of deformity is a constant and not a changing 
one. 



GREAT TOE DISEASE. 

Disease at the metatarsophalangeal joint of the first 
toe is not of very common occurrence. It is usually seen 
in adults or adolescents, and more often than other- 
wise following an injury. Cases are rarely seen before 
the disease is considerably advanced from neglect of 
treatment. The toe is more or less flexed, often ex- 
tremely so, and held rigid by muscular spasm, the joint 
is somewhat swollen, tender to pressure, and often hot 




Fig. 177.— Great-toe joiut disease with flexiou-deformity, 



to the touch. Walking is difficult, or impossible, be- 
cause of the flexion of the toe and the tenderness. • 

The mechanical treatment consists in restoring the 
toe to the normal position, and permanently holding it 
there. This is usually most conveniently accomplished 
by a plaster-of-paris dressing, renewed every week or 
two until the deformity is corrected. During this time 
crutches must be used. Afterwards immobilization may 



219 

be had by a rigid metal , insole, supplemented by a 
block of wood an inch thick fastened to the sole of the 
shoe and extending from the ball of the foot to the back 
of the heel. Or a strip of steel may be laid into the 
sole of the shoe reaching from the tip of the toe to the 




Fig. 178.— Great-toe joint disease with much swelling and sinuses. 




Fig. 179.— Shoe with block on sole and kid patch over joint. 

heel, and screwed fast. This must be rigid enough to 
prevent all bending of the sole of the shoe. If the joint 
is swollen and tender the leather of the shoe- upper 
should be cut away and a slack piece of kid inserted. 
The operative treatment consists in an erasion of the 



220 



diseased tissues as recommended in tarsal and ankle 
disease. The results of treatment at the great toe- 
joint are comparatively rapid, and in all cases that 
have been under our observation full normal motion 
has been gained. 



SHOULDER DISEASE. 

Chronic disease at the shoulder-joint is not of very 
frequent occurrence in either children or in those adults 
who, from the nature of their occupation, do not subject 
this joint to injury; but in certain classes of laboring 
men, who frequently subject their shoulders to strains, 
wrenchings, and contusions, and who from the neces- 
sity of unceasing toil are unable to await complete 




Fig. 180.— Head of humerus, sawed through in frontal plane; (a) wedge-shaped, 
completely separated sequestrum extending to denuded joint-surface; {bb) 
extensive cheesy infiltration of the head; secondary inftction from the 
sequestrum. (From Krause.) 



recovery from the injury, disease at this joint is more 
frequently found than elsewhere. Of these traumatic 
joints we shall speak later. 

When chronic disease at the shoulder-joint arises 
without any remembered injury, it has the same eti- 
ology as tuberculous joint-disease in the lower extrem- 
ity, which has already been discussed. It usually 



222 



commences as an osteitis ; rarely as a synovitis. The 
first focus in the bone is usually in the head of the 




YiG. 181. — Remains of the head of the left humerus in caries. Deep erosions. 
Contour of head indicated. (From Krause.) 




Fig. 182. — Upper end of the humerus in a case of dry caries. Head entirely 
gone, covered by a thin layer of firm tuberculous granulation-tissue. (From 
Krause.) 

humerus ; rarely in the glenoid cavity. Wherever the 
focus may begin it gradually extends until all parts of 



223 

the joints are involved. If the progress of the disease 
be rapid, liquefaction of the tuberculous material leads 
to the appearance of tubercular abscess ; if slow, the 
patient is said to be suffering from the dry form of the 
disease, and no abscess appears. In our experience 
tuberculous disease at the shoulder-joint is more fre- 
quently dry than otherwise. 




Fig. 183. — Dry caries of right humerus from front. Ankylosis, {a) Remains of 
head; (c) coracoid ; ((^) acromion ; (e) body of scapula sawed off. (Krause.) 

The traumatic form of chronic disease at the shoulder- 
joint, which is associated with adult life, has scarcely 
ever been referred to by writers. The chronic symp- 
toms gradually become engrafted upon a slight syno- 



224 

vitis and present characteristics quite different from 
tuberculous osteitis, rheumatism, or osteoarthritis. The 
course is much more benign than tuberculosis : it occurs 
in subjects who are strong and active ; it rarely, if ever, 
results in suppuration ; it invariably yields to treatment 
with but little variation in the length of time. From 
chronic rheumatism it may readily be recognized; it 




Fig. 184. — Cannot abduct the arm without pain. 



results from an injury, but does not immediately follow 
the acute symptoms ; it is always worse after exercise ; 
and is not accompanied by general rheumatism. With 
osteoarthritis it should rarely be confounded ; it never 
results in destruction or eburnation of joint-surfaces; 
rest never tends to stiffen, but always loosens the joint ; 



225 

it presents none of the characteristic symptoms of osteo- 
arthritis, and its clinical course has nothing in common 
with it. The patient may complain fitfully, often in 
accord with atmospheric conditions ; but it should be 
remembered that patients with fractures, injured mus- 
cles, and wounds often complain more in threatening 
weather. The arm is held closely to the side ; pain is 
complained of over the joint and often at the insertion 




Fig. 185.— Pain in trying to put the arm behind the back. 



of the deltoid muscle ; the patient is unable to sleep 
upon the shoulder, and should he accidentally lie upon 
it he awakens with pain ; acute pain is experienced 
upon pressing a point just below and to the outside of 
coracoid process which corresponds to the front of the 
humerus. There is an inability to rotate the joint either 



226 



inwards or outwards without discomfort. Abduction is 
limited, and elevation of the arm impossible. The sur- 
geon, in short, elicits from the patient the following 
story : " My arm is weak and painful : I dare not lie 
upon it at night, or the pain becomes incessant ; I can- 
not lift it from my side beyond a short distance; it 




Fig. 186. — Painful wheu tiying to place the hand behind the head. 



pains dreadfully if I attempt either [to get my hand 
behind my back or behind my head, and yet I can 
touch my opposite shoulder with no* discomfort and I 
can with equal ease push my arm forward." So correct 
is this clinical description that one need never be at 
loss to anticipate a patient's story. 



227 



Subsequently, shrinking of the shoulder-muscles takes 
place, and finally the limb may become wholly useless. 
If abscess forms, which certainly rarely ever occurs in 
this adult variety, the first true fluctuation will be made 
out in front of the joint. 

In tuberculous osteitis the first symptom is usually 
restriction to full rotation and to carrying the arm back- 




FiG, 187. — Can easily push the arm forward. 

ward. The patient finds that he cannot when dressing 
reach behind him and adjust his clothing with accus- 
tomed freedom and dexterity, and the arm is held 
hugged to the side. Shrinking of the muscles comes 
on early and is a constant symptom ; tenderness to 
pressure may be found over the outer anterior aspect 



228 

of the head of the humerus, and pain may be com- 
plained of at the insertion of the deltoid. The progress 
of the disease, unless aided by art, is from bad to worse. 
The complications are abscess and subluxation. The 
tendency of the tuberculous abscess is the same as else- 
where. If untreated, it descends as it approaches the 




Fig. 188.— Can easily touch the other shoulder. 

surface' and ultimately ruptures; if treated, a large per- 
centage gradually disappear without going on to spon- 
taneous rupture. Chronic abscess in the shoulder-joint 
escapes through the least protected parts of the capsule, 
and is subsequently directed in its course by structures 
which form a large shield over the joint. The joint is 



229 

supported and protected by two successive muscular 
coats, the first or deeper being intimately associated 
with the fibers of the capsule, the superficial protection 
being the deltoid muscle. The muscles touching the 
capsule consist of the subscapularis, long head of triceps, 
supraspinatus, infraspinatus, and teres minor, the three 
last being intimately blended into a continuous mass. 




Fig. 189.— Showing halter applied ; also beginning of 
apparent subcoracoid luxation. 

In this coat weak spots exist in two places, above and 
below the subscapularis. In the part above the capsule 
it is supplemented within by the long tendon of the 
biceps, which courses in the interval and escapes 
through a hole in the capsule, in the part below the 
capsule is thinnest and least protected. Pus having 
escaped through one of these undefended spaces finds 



230 

itself either under the deltoid, and is forced to point 
near the]Jfront or back of its insertion, or in the axilla. 
No attention has been drawn by previous writers to 
the pathologic displacement which occurs in a large 
number of tuberculous shoulders. It is not necessarily 




Fig. 190,— Arthritis with ankylosis. Pathologic displacemeut of head of 
humerus. 



dependent upon liquefaction of the head of the hunierus. 
It is almost always accompanied by ankylosis. This 
condition is not dissimilar in appearance to an old 
unreduced traumatic dislocation. The head of the 



231 



bone is not in reality very much out of position, but 
the capsule of the joint has become shortened, and this, 
in conjunction with the hugging of the arm and the 
marked atrophy of the deltoid, produces a strong like- 
ness to a subclavicular or to a subcoracoid luxation. 




Fig. 191.— Rear view of patient shown in Fig. 190. 



One of the authors (R. J.) has, on frequent occasions, 
been asked to reduce such shoulders, the patients and 
often their medical advisers failing to recognize the true 
nature of the lesions. We will briefly relate the his- 



232 

tory of a case by way of example, which shows the 
danger of not makmg a correct diagnosis. A gentleman 
brought his son, a youth of 19 years, to consult about 
his shoulder which, it was said, had been dislocated for 
over two years. He had already been to the metropolis 
and had consulted three surgeons of repute. One had 
suggested excision of the head of the humerus, another 
manipulation under anesthetics, and the third counseled 
a let-alone policy. All of them, however, acquiesced in 
the belief that they were dealing with a case of neg- 
lected dislocation. When the patient was examined 
we had no difficulty, even before inquiry into the his- 
tory of the lesion, in deciding that the case was one of 
pathologic subluxation following arthritis. The pa- 
tient's father became convinced of the correctness of 
this later view when we were able, without being 
prompted, to tell him the main outline of the course 
the diseased shoulder had gone through. The facts 
were briefly these : The boy fell from the box of a 
brougham upon his shoulder ; it was painful and swol- 
len. The family-doctor called next day, prescribed 
rest and evaporating lotions, and after a week's attend- 
ance left his patient with a few general instructions. In 
a fortnight after the accident he was able to use his 
shoulder, but with some discomfort. He always com- 
plained of pain on lying upon the joint. Examined 
two months later by an experienced surgeon, disloca- 
tion was pronounced, to the discredit and humiliation 
of the local practitioner, who fully believed he had 
made a serious initial error. In this case as in others, 
the differential diagnosis from an old traumatic dis- 
placement was not difficult. Ankylosis was complete, 
which is rarely the fact in neglected luxation. 

The muscular shrinking was more marked, the head 
of the bone less really displaced, and the coracoid more 
prominent than would have been the case in an old 




Fig. 192.— Showing muscular atrophy in shoulder-joint disease. 



234 

dislocation. How important, therefore, it is, both for 
the sake of the patient and the previous attendant, 
that the differences and the similarities between the 
two conditions should be noted: for it must be em- 
phasized that tuberculous arthritis of the shoulder 
without suppuration, often results in ankylosis, such 
ankylosis being an accompaniment of the pathologic 
displacement. 

The differential diagnosis of traumatic cases is mate- 
rially aided by the history of the injury, and, although 
rheumatism may attack an injured joint, too much 
credit must not be given to the rheumatic theory. Tu- 
bercular osteitis should not be mistaken for rheumatism 
because of the insidious onset and absence of early 
involvement of the soft parts. 

When shrinking of the muscles is extensive, and in 
cases that have experienced no pain, the part in appear- 
ance resembles certain spinal and traumatic palsies. In 
paralysis, however, there is abnormal passive mobility, 
while in joint-disease the mobility is diminished or alto- 
gether wanting. 

Without treatment the disease almost invariably re- 
sults in a shrunken, shortened, stiff and somewhat 
useless member. Under treatment, the shrinking, 
shortening and stiffness are lessened, and if commenced 
sufficiently early and faithfully carried out, a perfect 
cure not infrequently results with full restoration of 
normal function. 

The mechanical treatment of shoulder-joint disease 
is not by any means theoretically perfect, on account 
of the continued movement of the thorax and the 
shoulder girdle during respiration, though practically 
the results are good. Immobilization by leverage 
is not easily made; neither can the joint be satis- 
factorily held by any of the plastic dressings which 
surround the arm and chest. Traction can be a23plied 




Fig. 193.— Showing subclavicular luxation in shoulder-joint disease, accompanied 
by ankylosis. 



236 



more readily and perfectly than at any other joint, 
but its use aggravates the pain in most cases, and the 
treatment by traction gives less good results than at 
joints where it can be applied with less theoretical 
advantage. 

The treatment which we have found most useful con- 




Fig; 194.— Showiijg halter aud sirapping for the treatiueut of 
shoulaer-joint disease. 

sists in restraining voluntary movements by applying 
the " halter " about the wrist and neck, and at times a 
supplementary band from the elbow around the body. 
A restraining influence is brought to bear locally by 
covering the shoulder with numerous strips of pitch 
plaster spread on thick paper. These strips are laid on 



237 

one over the other, covering the shoulder and extending 
well down over the scapula on the back, and over an 
equal distance in front. 

In a few cases the weight of the arm gives rise to a 
dragging pain, and it is of advantage to support the 
member by a broad bandage passing from under the 
elbow over the shoulder of the opposite side. 

In shoulder-joint disease tuberculous abscesses can 
more readily than elsewhere be aspirated, and their 
cavities and fungoid masses injected with the iodoform 
mixture or other medicament, but, as elsewhere, this line 
of treatment has not been followed with good results 
except in an occasional case. 

The treatment of the adult variety of chronic shoulder- 
disease is the same as if it were tuberculous, namely, rest 
from pressure, friction and function. Treatment usually 
lasts from 3 to 5 months ; and the test of recovery most 
convenient for the practitioner is the patient's ability to 
sleep painlessly upon his joint. This form never results 
in ankylosis unless neglected. The test of recovery in 
tuberculous cases is in a fixed and painless ankylosis, 
or where ankylosis does not exist, a range of motion 
which may tend to increase, but never to diminish. With 
scapular movement always available, excision of the 
shoulder is never called for. 



ELBOW DISEASE. 

Chronic disease at the elbow-joint arises from 
neglected injury and from constitutional dyscrasia in the 
same way as does chronic disease at the other articula- 
tions. The joint is fairly frequently subject to injuries 
so slight that they are neglected and allowed to become 
ghronic ; but here, more frequently than elsewhere, do 
we find chronic disease following severe injuries. As a 
rule, joints suffering from dislocation or fracture are 
immobilized after reduction until a cure has been 
effected ; but the elbow forms an exception to this rule. 
The joint is so favorably situated for " surgical manip- 
ulations " and " passive motion " that few surgeons 
have been able to refrain from these most harmful pas- 
times, and as a result one is asked to treat a tubercu- 
lous elbow that would never have been tuberculous 
had it escaped such treatment for the original injury. 
We would not say that a dislocation at the elbow or a 
fracture into the joint should not be treated, but we 
believe that it would be better to leave such untreated 
than to commence forcible bendings before a complete 
subsidence of the inflammatory process. Tuberculosis 
may here, as elsewhere, commence as a primary or 
a secondary focus in the bone or in the synovial mem- 
brane; and as a synovitis it commences here next in 
frequency to the same condition at the knee. Chronic 
disease, the result of inherited syphilis, is not infre- 
quently met with at this joint. 

Disease following a neglected slight traumatism has 
its symptoms grafted on to those of the original injury. 
When first seen there is some obliteration of the nor- 
mal bony outlines ; thickening and some tenderness can 



239 

be made out between the olecranon and the condyles on 
either side, and there is some restriction to full flexion 
and extension, but no true involuntary muscular spasm. 
As the case progresses the swelling increases, the 
thickening becomes more pulpy and ultimately fluctu- 
ates, and sooner or later the bone is invaded, and then 
true muscular spasm restricts the joint motion. 




Fig. 195.— The halter applied in elbow-joint disease. 



A tuberculous synovitis presents no symptoms except 
swelling and a slight elastic restriction to full flexion 
and extension, until the bone is invaded or an abscess 
forms. 

Those cases which follow severe injuries and result 
from the efforts of the surgeon in the direction of pas- 



240 

sive motion follow much the same course. The thick- 
ening, the tenderness, and the restricted motion are still 
present when the passive motion is commenced, and 
they go on increasing until all the structures are in- 
volved and muscular spasm absolutely locks the joint. 

The symptoms of tuberculous osteitis are restriction 
to normal motion, a sense of w^eakness often accom- 
panied by an aching pain, and shrinking of the muscles 
both above and below the joint. When the tubercular 
focus has made its way out of the bone, whether into 
the joint or external to it, swelling appears, at first 
pulpy to the touch, and afterwards breaking down into 
a tubercular abscess, which presents in the majority of 
cases, below and to the outer side of the external con- 
dyle. The forearm becomes flexed from 40° to 70°, 
and motion is almost, or quite, lost. The bone-ends 
become thickened, and numerous sinuses appear, or in 
the dry form of disease little or no swelling and no ab- 
scesses may be present. 

The prognosis of elbow-joint disease without treat- 
ment is not often determined, for the surgeon is greatly 
prone to excise this joint. The results of excision are 
rather better here than at any other joint, but so also 
are the results of mechanical treatment without opera- 
tive interference. The ultimate result as to motion 
when treated mechanically depends of course upon the 
extent of the disease; a few joints recover ankylosed, 
but the vast majority regain normal motion when treated 
by efficient immobilization. 

The treatment consists in placing the member as 
rapidly as possible in such position as will prove most 
serviceable in case partial or complete ankylosis should 
result, and retaining it uninterruptedly in that position 
until a cure has been effected. The position of election 
is -that of complete flexion; such a position as will 
-enable the person to feed himself and dress his hair 



241 

should ankylosis result. If the forearm can be bent 
that far at once without considerable suffering, this is 
done ; if not, it is carried as far as possible towards the 
neck, and the head is bent as far forward as possible to 
meet it, and the halter is snugly applied. By the end 
of 2 or 3 days the head will have become erect and the 
forearm will have by that much approached the desired 
angle ; the head is again bent forward and the slack in 
the halter taken up. This is repeated until the desired 
position has been gained. The halter is then left at 
that length until the joint is cured. We are accustomed 
to fix the wrist to the neck in full flexion the moment the 
elbow is found to be effected. If this is done complete 
rest is secured for the joint, as the halter prevents ex- 
tension and the neck prevents flexion. If ankylosis 
threatens there will be ample time to drop the wrist to 
the most useful angle, and by this time the graver symp- 
toms will have abated. The useful angle in the case 
of a laboring man is about 90° ; in the case of a shop 
assistant, about 100° ; while many folks with ample 
means prefer an ankylosis at about 135°, which enables 
them to be less awkward at table. 

The halter consists of a piece of broad bandage suffi- 
ciently long to go around the wrist twice or thrice and 
thence around the neck. It may be fastened around 
the wrist with a " half hitch " or passed twice around 
and knotted. It must be loose enough not to constrict, 
and yet so tight that the hand cannot be drawn out of it. 
Near the neck the bandage is again knotted, and then 
tied around the neck. Sometimes the halter is left 
around the neck without interference for some months. 
In such cases if the surgeon can manage it the bandage 
should be passed through a tube of leather which acts 
as an excellent padding against the neck, and then 
through a leather band stitched around the wrist. 

All knots should be sealed to render it certain that 



242 

the dressing has not been tampered with. The dress- 
ing should be changed only when cleanliness demands 
it. Splints in the case of the elbow should be avoided ; 
they interfere by pressure on the vessels of the arm, 
check reparative processes, and materially increase the 
patient's discomfort. 

Operative procedures consist in aspiration of abscesses, 
injection of medicinal mixtures and excision. For the 
aspiration and injection treatment the elbow-joint is 
favorably placed, but there is no evidence to show that 
the ultimate cure is hastened by these measures in any 
but a few exceptional cases. Excision is more favored 
by general surgeons here than elsewhere because of the 
better functional results obtained ; nevertheless, we be- 
lieve that any joint that can be cured by an excision 
will get well without an excision and results in a far 
more useful arm. The most imperfect results obtained 
by mechanical treatment give a stronger arm than the 
best results from an excision. Only as a life-saving 
measure should excision be considered, and in such a 
circumstance the choice must lie between it and an 
amputation. 

The test of recovery in this joint is easily applied. 
It is founded on the principle that as disease advances 
motions become less. When the swelling has subsided 
and the patient feels his arm to be well, the experiment 
of testing is undertaken. The halter is lengthened two 
inches and the wrist allowed to drop ; if in a few days 
the patient is able to lift his hand to the point from 
which it was released, recovery is assured and the wrist 
may be allowed a further drop. If ankylosis has 
resulted, the test of its soundness may be made in 
accordance with the principle that a stiff joint is free 
from disease when it does not change its angle by use. 



WRIST DISEASE. 

GhTonic disease at the wrist-joint is of rare occurrence 
in children, except among the children of syphilitics. 
In adults it more frequently than otherwise appears to 
follow sprains and other slight but neglected injuries. 
In such cases it appears as a synovitis, and the promi- 
nent symptom is the swelling of the part. Cases are 
met, however, in which there is no swelling, and in 
which the restricted motion and muscular spasm point 
to an osteitic focus. In these cases, as in the tarsus, 




Fig. 196. — A tuberculous wrist with flexion-deformity and sinuses. 

swelling, as a rule, comes on early, and the part pre- 
sents heat, pain, restricted motion, and some deformity 
in the direction of flexion ; the patient usually present- 
ing himself supporting the diseased part with the other 
hand. Left untreated all motion is completely lost, 
and the hand may become flexed to a right-angle to 
the forearm. Abscesses form, as a rule, and are gener- 
ally met on the dorsum of the wrist and hand. 

The prognosis for mechanical treatment is good, both 



■pmpw 



244 

as to positipn and usefulness. The treatment can be 
most satisfactorily conducted by a simple splint of 
sheet-iron, bent to a hollow to fit the forearm and with 
a T-shaped ending at the hand. The part of the splint 
upon which the hand rests should be placed at an 




Fig. 197.— Using the wrench to break up an ankylosed wrist. 

angle of about 140°, and the lateral wings should be 
bent around and grasp the hand at the metacarpo- 
phalangeal articulation, the whole being held in place 
by strips of adhesive plaster. The flexion should be 




Fig. 198.— a 



lint of sheet metal for the treatment 
of wrist-joint disease. 



overcome as rapidly as possible, and the hand immo- 
bilized in an extended position. This extended posi- 
tion is of great importance in the treatment of the wrist 
and is not referred to by any writers on the subject. 
If one wishes to grip powerfully, the wrist is first in- 



245 




246 



stinctively extended. One cannot grip effectively with 
the wrist flexed. The lesion is obvious. If disease at 
the wrist results in ankylosis in the extended position 
every advantage will accrue for subsequent action of 
the extensors of the hand. So true is this that when a 
patient consults us complaining of faulty use of the 
fingers, should the wrist be ankylosed in the flexed 




Fig. 201.— The position of the wrist for a weak grip 




Fig. 202.— The most advantageous angle for the wrist to give a strong grip. 

position, we promise improved power in the grasp 
when the ankylosis has been attacked by the wrench 
and the wrist placed in extension instead of flexion. 
The forearm is then suspended in a sling or halter. 
The management of abscesses is the same as at other 
joints. Excisions and erasions are no more demanded 



247 

than elsewhere, and, as at the tarsus, are more muti- 
lating in their results than at the larger joints. As a 
life-saving measure they may be demanded, as may 
amputation. 



CARPAL, METACARPAL, AND PHALANGEAL 
DISEASE. 

Chronic disease of bones of the hand, apart from 
wrist-joint disease, is very rare except in children and 
young adults. In most cases inherited syphilis is 
acknowledged or reasonably suspected. In the carpus 
and metacarpus the bones become thickened, and 
abscesses develop early. In the fingers, it is usually 
the proxymal phalangeal joint that is affected; the 
distal end of the first phalanx and the proxymal end 
of the second phalanx become thickened and the finger 
assumes a spindle shape, suppuration occurs 'and evi- 
dences of tuberculosis are found ; nevertheless these 
cases respond to antisyphilitic remedies in a way that 
marks them as quite apart from ordinary tuberculous 
joints. 

The mechanical treatment consists in splinting on 
the palmar surface. The operative treatment consists 
in subperiosteal erasion of the disease in the bones of 
the carpus and metacarpus, and in amputation of the 
fingers. If medicinal treatment is resorted to, rapidly- 
increasing doses of mercury and iodid of potash should 
be given until the constitutional effects are produced 
or the disease subsides. 




Fig. 203. — Disease of the metacarpal bone and of the finger-bones, 
characteristic of inherited syphilis. 



RACHITIC DEFORMITIES. 

The chief rachitic deformities with which the ortho- 
pedic surgeon has to deal are : Bowlegs, knockknees, 
spinal curvature, and chicken-breast. The deformity 
known as coxa vara will also be discussed, as well as 
adolescent rickets. The rachitic condition which leads 
up to these deformities will first be considered. 

Rickets, or rachitis, is a disease of early childhood. 
It is chiefly characterized by distortion of some or all 
of the bones. The distortion is due to irregular 
growth and deficient rigidity of the bony structure. 

The etiology of rickets is obscure. Many causes have 
been assigned by different observers, and any one, or 
all, may be the chief etiologic factor in any given case. 
The disease rarely develops after the third year of life ; 
by far the greater number of cases appearing during the 
second year, during the months subsequent to the wean- 
ing of the child. Evidence of rickets is occasionally 
found at birth, and a certain number of rachitic de- 
formities, especially of the long bones, develop at about 
the period of adolescence. 

A small number of rachitic children appear to owe 
their disease to the last months of nursing when the 
mothers have again become pregnant. Among the 
wealthy we find rickets chiefly among bottle-fed babies, 
or in those of syphilitic ancestry. Among the poor, 
in addition to the above, improper food, bad air of 
crowded and ill- ventilated rooms, lack of sunlight, and 
uncleanly personal habits may be regarded important 
causative factors in this disease. 

In New York City fully ^^ of the rachitic children 
observed by one of the authors (J. R.) were among the 
poorer Italians, who live in dark, damp, and crowded 



250 

rooms ; the children are seldom washed, and are per- 
mitted to eat anything that comes within their reach. 
Of the remaining 2^ fully 27 were colored children of 
a class notoriously syphilitic ; the remaining -f^ were 
about equally divided between bottle-fed babies and 
those of syphilitic ancestry. 

In Chicago, where there are relatively fewer poor 
Italians, and where all classes of the poor are better fed 
and better housed, and enjoy more sunlight and pure 
air than in New York, there are comparatively few 
rickety children. The larger number of rickety chil- 
dren that have come under our observation are the 
children of colored people, presumably syphilitic ; there 
are a considerable number from the children of Ara- 
bians and Syrians ; and a relatively large number are 
children who have been nursed by pregnant mothers. 
Recently we have seen quite a large number that have 
been fed upon sterilized milk, and upon various brands 
of proprietary infant foods. 

Parrot believed that all cases of rickets were due to 
inherited syphilis ; that rickets was inherited syphilis ; 
but the view of Fournier is probably nearer correct, 
that syphilis produces rickets indirectly by being one 
of the causes of malnutrition. In this connection it 
may be stated that many cases of rachitic deformity are 
due to irregular growth at the epiphyseal lines instead 
of a bending of the softened shaft of the bone, and that 
the seat of election of inherited bone-syphilis is at this 
point, the epiphyseal junction. 

Macewen, of Glasgow, told Dr. Ridlon some years 
ago, at a time when he had operated upon over 1,200 
rachitic deformities of the lower limbs, that diet ap- 
peared to him to play a much less important part than 
sunlight, pure air, and cleanliness ; that the diet of the 
poor of Grlasgow was practically the same as that of 
the poor in the Highlands, but that while having seen 



251 

«uch an enormous number of rachitic deformities he 
had never seen one in a child reared in the High- 
lands. 

It seems somewhat strange that rickets should be 
rarely found among the. very poor in Ireland, but the 
observation is beyond question. Despite the fact that 
these children are underfed and illfed, housed in 
crowded and dirty hovels without floors or means of 
admitting sunlight or pure air, they rarely become 
rachitic. It has been observed that rickets occasionally 
is seen in the children of men who have been across to 
England for the harvest season and presumably have 
been exposed to venereal infection. The query 
naturally arises : Do the children of Ireland escape 
rickets because of the moral purity of the lives of their 
parents ? 

In Japan, where moral purity is not counted as one 
of the crowning virtues, and where syphilis, possibly 
contracted from foreign sailors, is not unknown, medi- 
cal missionaries find no rickets. They account for this 
on dietetic and hygienic theories. The Japanese live 
much of the time out of doors ; their houses are of so 
flimsy a build that ventilation is perfect; they bathe 
every day, and from the earliest childhood fish forms 
an important part of the dietary. Mothers in childbed 
eat fish, and nursing children are fed upon fish as soon 
as they receive any food except the mother's milk. 
From this, one must conclude that syphilis does not 
always beget rickets, despite the fact that while the 
native African is free from rickets the Americanized 
and syphilized African is the father of rachitic chil- 
dren. 

The infectious diseases of childhood, especially 
whooping-cough, and the digestive disturbances of in- 
fancy often precede the onset of rickets ; but perhaps 
the most that can be fairly said upon the subject of 



252 

etiology is, that anything which causes malnutrition 
in a young child may lead up to the development of 
rickets. 

Even less is known of the pathology than of the 




Fig. 204.— Congenital rickets, showing bowlegs. 



etiology. The new bone formed beneath the perios- 
teum is soft and deficient in earthy matter, and in some 
instances the animal matter does not yield gelatin on 
boiling. The epiphyses are enlarged, and ossification 



253 

proceeds slowly and irregularly. The border of ossifi- 
cation, instead of being a clearly defined straight line, 
is serrated, the new bone shooting into the cartilage 
and the cartilage extending for some distance along 
the shaft of the long bones. The medullary cavity is 
advanced beyond the border of ossification and is filled 
with a reddish, pulpy material. The lamellae of the 
bone are loosely inposed, one upon the other, and in 
some fresh specimens may be peeled off. The same 
defective development is found in the flat bones. 

The liver, spleen, and lymphatic glands are often 
enlarged, and the quantity of white brain-substance is 
increased. The muscles are pale and flabby and the 
ligaments are relaxed. 

The early symptoms of rickets are indefinite, and the 
onset insidious. The child is restless and yet not in- 
clined to play about ; is peevish and yet is happier 
when left alone than when held in the arms or carried 
about ; tosses about in sleep, kicks off the bedclothes, and 
perspires much about the head. The appetite is good, 
but the child does not thrive ; there is some looseness 
of the bowels, or constipation and diarrhea alternate ; 
the abdomen becomes prominent ; the bone-ends, par- 
ticularly at the wrists and ankles, become enlarged and 
may be tender on moderately strong squeezing; the 
tibias may bow outward, or forward, or both outward 
and forward; the femora may bow in the same direc- 
tion ; there may be knockknee from elongation of the 
inner condyle of the femur, or outknee from elongation 
of the outer condyle, or either deformity may result 
from abnormality of the upper end of the tibia, or one 
knee may be distorted inward and the other outward. 
With bowlegs the feet are often flattened, and with 
severe knockknee the knees are often held some- 
what flexed ; with severe deformity in the legs and 
thighs there is usually some flexion at the hips, the 



254 



pelvis is tilted forward, and there is lordosis of the lum- 
bar spine. Associated with this tipping forward of the 
pelvis the weight of the body is brought to bear through 
the spine upon the sacrum in such a way that the sac- 
rum is displaced forward and downward from the iliac 

bones, sometimes even 
to the full thickness of 
the bone, by that much 
diminishing the diam- 
eter of the pelvis. At 
times also the ace- 
tabulae approach each 
other, pushing the 
symphysis pubis for- 
ward and narrowing 
the pelvis laterally. 
The pelvic circle then 
becomes somewhat 
heartshaped, the point 
being to the front. 

The sternum in the 
same way points promi- 
nently forward, the ribs 
sinking away on either 
side until the chest 
resembles the keel of 
a boat (pectus carina- 
tum), or the breast- 
bone of a fowl (chicken- 
breast). At the junc- 
tion of the ribs and their cartilages there is often so 
decided a thickening or beading that it can not only be 
felt, but can be seen. This is called the rachitic rosary. 
The lower border of the ribs flares out, because of the 
enlarged spleen and liver and the distended bowels. 
The spine is often bowed backward in the dorsolumbar 




Fig. 205. — Congenital rickets, showing 
knockknees. 



255 

region, so much so as to closely resemble the kyphosis 
of spondylitis, and if it is held rigid because of the 
tenderness of the bones the diagnosis between a spondy- 
litic and a rachitic curvature may be very difficult. 
The bones of the arms may be bowed like unto the legs, 
and the scapulae and collar-bones may also be dis- 
torted. The head is often of a characteristic appearance. 
It is flattened at the top and at the sides, the occiput 



li /h-;^Mi'' 




FlG. 206.— Eachitic curvature of the spine. 



Fig. 207.— Bowlegs in an infant. 



and frontal bosses are prominent, and the headfviewed 
from above suggests a square (caput quadratum). The 
face is small when compared with the head as a whole. 
The lax ligaments, weak muscles, and tender bones 
render weight-bearing difficult, and these children 
consequently walk late, rarely before the fifteenth 
month, and often not before the end of the second or 
third year. Contrary to the general impression, chil- 



256 

dren that walk at an early age do not develop bowlegs 
and knockknees, while those that walk late are very 
subject to these deformities. The teeth usually appear 
late and at irregular intervals ; they are poorly formed 
and soon decay. Sooner or later solidification of the 
soft bones takes place, the process is usually a very 
rapid one, and the bone becomes unnaturally hard and 
ivory-like. 

It is pretty generally believed that rachitic deformities 




Fig. 208.— a case of bowlegs affecting the upper 
third of the leg bones. 

in the bones, particularly the outward bowing of the 
tibias, disappear. We are of the opinion that actual 
straightening of the bones does not take place, and 
that the true curve always remains, but there can be 
no doubt that the deformity, as a whole, appears to 
be less. This, we think, is due to the filling in of the 
concavity by the muscular development, to the greater 
length of the bones, to the tightening up of the liga- 



257 

ments, and to an increased muscular strength which 
enables the patient to carry himself in the best possible 
position for obscuring his deformity. These victims 
never attain their full stature. 

The prognosis as to life is good, except in those 
young cases complicated with bronchitis and laryngis- 





FiG. 209.— A case of unilateral bowleg. 



Fig. 210. — A case of outkneein which 
there is little apparent deformity 
in the leg and thigh bones. 



mus stridulus. The deformity, as a rule, steadily in- 
creases until the bones become solidified. In knock- 
knees the deformity may even increase after the bones 
have become solidified. 

The general treatment is to improve the nutrition . Of 
chief importance are the following : Life in the open 



258 

air and free exposure to sunlight. Light, dry. and 
well-ventilated rooms. Daily bathing, preferably in 
salt water or sea-water. An abundance of good food 
in which fish. fat. and fruit play a prominent part. 
The fish should be fresh and cooked with an abundance 
of butter, which, by the way. is the secret of the proper 
cooking of all fish. Fish should be given at least 3 times 
each week. Fat in the form. of cream and butter in 
abundance wherever it can be used, and fried fat 
bacon. Butter will usually be taken more freely if un- 
salted or only half salted. Bacon should be cut thin, 
placed for a short time in iced water, carefully dried, and 
then placed in a hot pan without fat other than its own. 
AVhen cooked it should be placed on grocers' ordinary^ 
brown paper to allow the excess of grease to drip off. 
Properly cooked it may be taken in the fingers without 
greasing them, and should be as brittle as a cracker or 
biscuit. Children will eat this with avidity twice a 
day. 

Fruit in season should be given freely, and at such 
times as the child may crave it. Bread soaked in gravy 
or in milk should, as a rule, be avoided ; and many of 
these children do not do well on oatmeal and other 
kinds of mush. 

The only medication that has given us any satisfac- 
tion is phosphorus and codliver oil, with the iodid of 
iron in an occasional case and mercury and potassium 
iodid in the children of syphilitics. The various hypo- 
phosphites we believe to be useless. Phosphorus should 
be given in doses of from -^hr ^^ tto grain. The elixir 
of free phosphorus is an acceptable preparation for pri- 
vate patients, and the oil of phosphorus in codliver oil 
is the most convenient in dispensary work. If the 
sirup of the iodid of iron is used it should be 
given with a free hand, and if mercury and potassium 
iodid are indicated they should be given in rapidly 



259 



increasing doses until the physiologic effect is pro- 
duced. 

The mechanical treatment will be considered under 
the headings of the various deformities, as will the 
operative treatment. 




Fig. 211.— a case of bowlegs with inability to fully extend the knees. 

Chicken-breast: Treatment by an elastic pressure- 
pad has been found of no avail, and little is ever accom- 
plished in the way of actually correcting the chest- 
deformity by any form of treatment. A demand is 
often made that these cases be treated, and generally 



2(;o 



enough gain can be had to satisfy the parents. We are 
accustomed to have these children come to us daily for 
exercises for a period of at least three months. The 
exercises aim to increase the chest capacity, to reduce 
the dorsal kyphosis (round shoulders), the lumbar 
lordosis (sway-back), and the protruding abdomen. 
They are as follows: 

1. Back-lying, arms down, breathe deeply 10 to 20 
times. 





Fig. 212. — A case of bowlegs with 
inability to fully extend the 
knees. 



Fig. 213.— Knoctknees in an infant. 



2. Back-lying, arms straight, grasp the ends of a stick 
15 inches long, the surgeon pulls upward while the pa- 
tient pulls downward, each alternately resisting, the 
stick making excursions from- the thighs of the patient 
to the table above his head, 10 times. 

3. Back-lying, arms stretched out and palms up, 
breathe deeply 10 to 20 times. 



261 

4. Back-lying, grasp stick as in exercise 2, the patient 
pulls upward while the surgeon 2>ulls downward, each 
alternately resisting, the stick making excursions from 
the thighs of the patient to the table above his head, 10 
times. 




Fig. 214.— Knockknees and bowlegs in the same patient. 

5. Back-lying, hands up,breathe deeply 10 to 20 times. 

6. Back-lying, arms straight, the surgeon grasps the 
patient's hands, each alternately pulling and resisting, 
the arms make an excursion from the patient's thighs 
horizontally to a point above his head, 10 times. 



262 



7. Back-lying, knee straight and stiff, foot extended, 
circle the legs, first one and then the other, 10 times. 

8. Back-lying, knees held down, hands on hips, or 
stretched out, or locked at the back of the head, rise to 
the sitting posture, 10 times. 

9. Back-lying, hands on hips, neck stiff and whole 
body rigid, the surgeon with his hands under the pa- 
tient's head raises him 10 times. 





Fig. 215.— a case of knockkuees. 



Fig. 2i6.— a case of knockknees in 
which the deformity wholly dis- 
apiiears as soon as the knees are 
somewhat flexed. 



10. Face-lying, hands on hips, or stretched out, or 
locked at the back of the head, legs held down, raise 
head and shoulders upward and backward, 10 times. 

11. Face-lying, knees straight and feet extended, cir- 
cle le^s, first one and then the other, 10 times. 



263 

12. Horizontal-bar hanging, deep breathing, 10 to 20 
times. 

The order of the exercises, and their number and 
repetition must be graded to the strength of each case. 
All cases of rachitic deformity of the chest should be 
carefully examined for adenoid growths in the naso- 




FiG. 217.— Rachitic deformity of the chest. 



pharynx, or for other obstructions to the breathing ; if 
found, all such should be removed. It is claimed by 
Redard, of Paris, that a careful examination will reveal 
some obstruction to breathing in all cases of this kind. 
Rachitic Curvatures : Rachitic curvatures of the spine 



264 

may be posterior or lateral, or both posterior and 
lateral. 

The lateral curvatures so closely resemble scoliosis 
that they cannot be distinguished from that condition. 
Indeed, most writers include rachitic lateral curvatures 
under scoliosis and class rickets among the causes of 
scoliosis. The treatment consists in holding the pa- 
tient as straight as possible in a jacket or brace, as 
continuously and for as long a time as possible. The 
treatment is difficult of accomplishment and the results 
are far from satisfactory. 

The posterior curvatures are usually in the dorso- 
lumbar region. The curvature is usually long and 
rounded, and if it is stiff, as it often is on account of 
the tenderness of the bones, it may be impossible to 
diagnosticate it from spondylitis unless there are other 
well-marked rachitic manifestations. The diagnosis, 
however, is not important, inasmuch as the mechanical 
treatment is by a brace of the same form and used in 
the same manner as in a like spondylitic curvature. 
The rachitic posterior curvatures always straighten, that 
is to say, the deformity is fully corrected. 

Bowlegs: Bowlegs consist of a bowing outward or 
forward, or in both directions, of the bones of the leg, 
often accompanied by a bowing of the femur in the 
same direction, and associated with lax external lateral 
ligaments at the knee-joint. Occasionally one sees true 
outknee, due to an actual lengthening of the external 
femoral condyle or the outer side. of the head of the 
tibia. When outknee is associated with an outward 
bowing of the femur and leg-bones, the limb, taken 
as a whole, may form an almost complete semicircle. 
The outward curve in the bones of the leg is usually 
near the upper or lower epiphyseal lines, although it 
may be in the middle of the shaft. The anterior curve 
almost always occupies the lower third or half of the 
tibia. 



X 



265 

Mechanical treatment will correct the lateral de- 
formity of the bones of the leg so long as the bone 
remains soft ; but if the bones have hardened operative 
treatment must be resorted to. Anterior curvature of 
the tibia cannot be corrected by braces, and should be 
submitted to osteoclasis or osteotomy at once. Out- 
knee can always be corrected by proper braces, even 

after hardening of the bones. 
If, however, the outknee be 
solely due to a lengthening 
of the outer condyle, it may 
be better, except in the very 
young, to do Ogston's opera- 
tion, separating the outer con- 
dyle and allowing it to slip 
up far enough to correct the 





Fig. 218.— Unilateral knockknee. Fig. 219.— The Thomas bowleg brace. 



deformity. Bowing of the femur is seldom sufficiently 
severe to demand treatment. 

In bowlegs, when the bones are very soft, it is often 
possible to correct the deformity by the use of plaster- 
of-paris. The plaster bandages should be rapidly ap- 
plied, and before the plaster sets a piece of stiff board 
splinting is bound to the outer side of the leg (the con- 



I 



266 

vexity of the curvature) by an ordinary muslin roller- 
bandage. The roller and board-splint are removed 
when the plaster has set. 

The simplest and most efficient brace is a strip of flat 
bar-iron reaching from the upper end of the tibia along 
the concavity of the curve to the heel of the shoe where 
it is bent to a right angle and passed into a hole or a 
tube set in the heel of the shoe. The bent portion is 
forged round so as to permit motion at the ankle-joint. 
A padded iron band half encircles the ankle; this 
may be completed by a leather strap. A like band is 






Fig. 220. — The Thomas knockknee brace. 

placed at the garter-line below the knee, and a pad 
rests against the head of the tibia. The curvature is 
drawn toward the straight splint by a broad strap and 
buckle or by an ordinary roller-bandage. When the 
deformity involves the knee the side bar is extended 
up against the thigh, and a posterior bar is added like 
that in the knockknee brace to be described later. 

After the deformity has been corrected for some 
time, if any laxity of the ligaments of the knee remains 
it may be well to put on the conventional leg-braces ; 



267 

these consist of a strip of light steel on each side of the 
leg from the upper part of the thigh to the shank of 
the shoe, where it is riveted. Free anteroposterior joints 
are made at the knee and ankle, with pads at these 
points. A strong padded band joins the bars at the 
top around the back of the thigh, and this is completed 
across the front by a strap and buckle. A like band is 
placed at the garter-line. At times a strap encircles 
the leg and inner bar at the point of weakness in the 
tibia. 

KnocHiiee : Knockknee, also known as inknee, re- 
sults from a lengthening of the inner femoral condyle, 
or a shortening of the outer condyle, or a combination 
of both, although in some cases it is due to an elonga- 
tion of the inner side of the upper end of the tibia. A 
certain degree of false knockknee may result from a 
laxity of the inner lateral ligaments of the joint. 
These cases of false knockknee can be cured by retain- 
ing the limb in the conventional leg-braces just de- 
scribed under bowlegs, until the slack in the elongated 
ligaments has been taken up by structural shortening. 

Knockknee at any stage may be cured by proper 
braces, but brace- treatment on account of its long dura- 
tion is hardly justifiable in cases past adolescence. In 
the younger cases it may be the best treatment in bilat- 
eral cases, but in unilateral cases the choice of treatment 
must depend upon the nature of the deformity. If the 
inner condyle be markedly lengthened, straightening by 
a brace results in lengthening of the entire limb, which 
may prove as great a disability as the knockknee. Such 
a condition should be subjected to Ogston's operation, 
to be described hereafter. 

It is the custom of many surgeons and all instrument- 
makers who are called upon to treat cases of knockknee 
to apply the conventional leg-braces already described, 
with the addition of a large pad at the side of the inner 



268 

condyle. This treatment for the correction of the de- 
formity is absolutely useless. The secret of success in 
the brace-treatment of knockknee is in keeping the 
joint fully extended (straightened anteroposteriorly), 
while applying the lateral corrective pressure. The 
elongation of the inner condyle is only in the down- 
ward direction, not at all backward, and the full degree 
of deformity is apparent only when the joint is fully 
extended. As soon as flexion begins the corrective 
pressure-strain of the brace is relaxed and soon becomes 
nil; all knockknee deformity disappears long before 




Fig. 221.— The Rizzoli osteoclast 



voluntary flexion reaches 90°. Therefore, when any 
degree of corrective pressure is applied by braces hav- 
ing a free anteroposterior joint at the knee the patient 
flexes his legs slightly and all pressure is removed. 
When, however, the deformity has been fully corrected 
by operative or mechanical means these braces serve 
well as a retentive measure. 

The simplest brace for the treatment of knockknee 
consists of a strip of flat iron placed along the outer 
side of the limb, reaching from the greater trochanter to 
the sole, forged round at the bottom, bent at a right 



269 



angle, and passed into a hole or a tube in the heel of 
the shoe ; attached to this at the ankle is a padded iron 
band extending about two-thirds around the limb ; at 
the upper part of the thigh is a like band, and these 
bands are joined by a strip of iron placed directly back 
of the middle line of the limb. At the top of the side 
bar is a pad from two to three inches in diameter. The 
limb is first bandaged to the posterior bar, securing the 
knee in full extension, and then to both bars, stretch- 




FiG. 222.— The Grattan osteoclast. 

ing the knee in the direction of correcting the deform- 
ity. This corrected position is constantly maintained 
until the deformity is not only corrected but readily 
remains so; then the jointed retention-braces may be 
applied and joint action permitted. 

Plaster- of-paris may be used in the treatment of knock- 
knee after the same manner as suggested in bowlegs, 
but it is less efficient. If it is used the limb must be 
firmly held by two persons while the plaster is setting, 



I 



270 

or a strip of splinting may be bandaged on at the side 
and another at the back of the limb. 

The operative treatment of bowlegs and knockknees con- 
sists in an osteoclasis or an osteotomy of the bones at 
the points of election. Osteoclasis is the making of a 
simple fracture, either by hand or by the aid of a 
specially devised instrument termed an osteoclast. 
Osteotomy is the making of a compound fracture by 
the use of cutting instruments for dividing the bone 




Fig. 223.— The Thomas osteoclast. 



two thirds of the way, supplemented by manual fracture 
of the remaining third of the bone. 

Osteoclasis by the use of the hands of the surgeon 
alone is not so easy a matter as at first appears. Com- 
paratively few are able to break the leg bones of a child 
of 2 or 3 years. When no other means are at hand the 
leg can sometimes be broken over the edge of a table 
by the surgeon throwing his weight upon it. In this 
way it is not possible to fracture very accurately or very 
near the end of the bone. The correction of knockknee 



271 

manually usually results either in tearing the outer 
lateral ligament or in partially tearing off the epiphysis. 
In either instance, however, the case usually does well 
provided the limb is supported for a sufficiently long 
time. 

Mechanical osteoclasis is accomplished by a specially 
devised instrument called an osteoclast. The numer- 
ous forms of this instrument exert a breaking force in 
one of two ways, namely, by screw-pressure, or by 




Fig. 224.— The Thomas osteoclast in use. 



leverage pressure. Those working by screw-pressure 
are the most powerful and the most acurate ; those work- 
ing by leverage are the most rapid in their action, and 
consequently do less damage to the soft tissues covering 
the bone. 

The Rizzoli osteoclast has been extensively used be- 
cause of its simplicity and cheapness. It consists of a 
heavy bar of steel, 1 inch by l^inch, and 15 inches long, 
through the middle of which plays a screw with a 



272 

handle at one end and a padded crutch at the other. 
On either side of this screw two steel loops are made 
to slide on the bar and fasten with thumbscrews. These 
loops are padded, and of sufficient size to admit the 
limb about to be broken. The instrument always 
breaks the bone transversely at the point where the 
crutch bears. The objection to the instrument is the 
manipulation to which the fracture is subjected in re- 
moving the instrument from the limb. In case the in- 
strument is poorly constructed, and weak at the screw- 
hole, it may bend when in use, and its removal from the 
limb can not be effected except with the aid of a black- 
smith. 

Cabot's osteoclast is a modification of the Rizzoli by 
changing the loops into hooks, rendering its removal 
possible even if it should bend when in use. 

Grattan's osteoclast is the one most generally in use 
among orthopedic surgeons in England and America at 
the present time. It consists of a strong post resting 
on a cross-bar. Upon the post are hinged two strong 
hooks, made to separate or approach each other by set- 
screws. Through the post plays a strong screw with a 
handle at one end and a pressure-bar at the other. 
This pressure-bar is steadied by a guide playing through 
a notch in the top of the main post. The instrument 
is not padded, but made of polished steel. The pres- 
sure-bar is ovoid on cross-section, with the smaller end 
of the oval directed away from the post and towards 
the limb to be broken. The instrument is the most 
powerful of any osteoclast that we have used. 

The Thomas osteoclast consists of two steel bars 
joined in a hinge. At the point of the hinge an upright 
post is raised for the middle pressure-bar. A movable 
arm is attached to each bar a short distance back from 
the hinge ; at the free ends of these arms on each a post 
is raised, and these form the outer pressure-bars. When 



273 

the long bars are opened the outer pressure-bars go to the 
far side of the bone to be broken, while the middle pres- 
sure-bar impinges against the convexity of the curve ; 
then when the long bars are made to approach each 
other the outer pressure-bars draw near while the middle 
pressure-bar goes out and the fracture is effected. The 
action of the instrument is very rapid, but it is not 
possible to break very close to the end of a bone. 

The Eidlon osteoclast was devised with the idea of 
combining the accuracy of the Grattan with the rapidity 




Fig. 225.— Ridlon's osteoclast. 



of the Thomas. It consists of a flat steel bar, raised 
somewhat upon a rest ; on the bar slide two hooks, 
fastened by thumbscrews ; raised slightly above the bar 
are two toothed wheels ; these are turned by two re- 
movable handbars ; between the toothed wheels plays a 
toothed bar, at the end of which is the pressure-bar. 
The limb to be broken is laid in the hooks, and they 
are placed as desired and made fast ; then the pressure- 
bar is run down against the limb, and the handle-bars 
adjusted at a convenient angle ; when these are brought 



274 

together the pressure-bar is driven forwards by the turn- 
ing of the wheels and the fracture is effected. 

The Robin, the Cohn, and the Lorenz osteoclasts are 
complicated, expensive, and less efficient than those 
already described. They are not used by English and 
American surgeons. 

After osteoclasis, the limb is wrapped with cotton- 
wadding bandages and covered with a plaster-of-paris- 
dressing. After fracture of the bones of the leg the 
plaster- dressing should extend from the toes to the 
middle of the thigh. After fracture of the femur it 
should extend from the toes to and around the waist. 
Fixation of the fracture should be maintained from 4 
to 5 weeks. After removal of the plaster in cases of 
knockknee it is usually well to support the limbs with 
the conventional leg-braces for some months. 

Osteotomy is of two kinds: linear and cuneiform. 
Linear osteotomy consists in driving an osteotome two- 
thirds or three-fourths through the bone and then frac- 
turing the remainder by manipulation. Cuneiform 
osteotomy consists in removing a wedge-shaped piece^ 
of bone from the convexity of the deformity by means 
of a chisel and breaking the remainder by manipula- 
tion. The osteotome will be described under Macewen's 
operation for knockknee. The chisel used in cuneiform 
osteotomy is shaped like a carpenter's chisel, being a 
flat piece of steel with parallel sides and at the end 
beveled on one side by grinding to an edge. 

Linear osteotomy may be the operation chosen for 
the correction of the lateral deformity of bowlegs. The 
section is made at the point of greatest deformity, and 
after the manner to be described later as Macewen's 
operation for knockknee. 

Cuneiform osteotomy may be chosen for the correc- 
tion of the anterior deformities. A wedge is removed 
from the part of greatest convexity by means of the- 



275 




chisel. The thickness of the base of the wedge depends 
upon the sharpness of the curve. The wound through 
the soft parts is in the line of the shaft of the bone ; 
this is held open by retractors and the wedge removed 
transversely to the long axis of the bone. As a rule the 
flat side of the chisel is towards the longer portion of 
the bone and shavings are pared off from that side 
towards which the beveled side of the chisel looks. 
When a sufficient wedge has been removed the bone is 
broken by manipulation. 

Osteotomy for knockknee, in so far as we know, was 
first performed by Ogston of Aberdeen, Scotland, on 
May 17, 1876 ; he sawed off the inner condyle of 
the femur. All opera- 
tions on the inner con- 
dyle are modifications of 
this. On February 2, 
1878, Macewen, of Glas- 
gow, Scotland, first did 
the operation known by 
his name, using the os. 
teotome and making a 
section of the femur 
above the condyles. 

Ogston's operation consists in the following procedure: 
The patient is fully anesthetized ; the limb rendered 
bloodless ; the leg is fully flexed on the thigh, and the 
thigh rotated somewhat outward ; a long tenotomy knife 
is introduced flatly, two or three inches above the tip of 
the inner condyle and pushed downwards, forwards and 
outwards until the point is felt in the inter-condyloid 
space; the cutting edge of the knife is then turned 
directly towards the bone, and as it is slowly withdrawn 
all the soft tissues are divided down to the bone, and 
the external wound made sufficiently large to admit the 
blade of an Adams saw. This saw has a long narrow 




Fig. 226.— Ridlon's sacral table for sup- 
porting the hips when applying a 
plaster spica bandage. 



276 

shank, a cuttiDg edge about an inch and a half in 
length, and a blunt point. The saw is introduced along 
the canal made by the knife ; its cutting edge directed 
towards the bone and the condyle sawed through about 
three-quarters of its thickness. The saw is then re- 
removed ; the leg extended upon the thigh ; and with 
a sudden forcible effort in the direction of straightening 
the knockknee the undivided portion of the condyle is 
fractured ; the fragment slides up and the deformity is 
corrected. 

The operation throughout must be strictly asejDtic. 
The wound is closed without drainage ; the dressings 
are applied ; and the fractured bone is put up in a 
plaster-of-paris spica, or a wooden side-and-back splint. 

The objections to the operation are, that the joint is 
opened ; sawdust remains in the wound, and perhaps 
also in the joint; and an irregular joint surface or fault 
remains at the point of fracture, due to the slipping up- 
ward of the separated condyle. The advantages are 
that a normal length of limb results when the deform- 
ity has been solely due to an elongated inner condyle, 
a matter of no small moment in unilateral cases of 
knockknee. 

Reeves' operation aims to avoid the sawdust by using 
an osteotome in place of a saw. The osteotome is 
driven along the same line as that followed by the saw 
in Ogston's operation, and the operator aims to stop 
short of the encrusting cartilage, and to leave the joint 
unopened. Most operators, however, believe that the 
joint is always opened in this operation. 

Chiene's operation aims to avoid opening the joint 
by removing a wedge of bone from the inner condyle 
by means of a chisel. The base of the wedge includes 
some considerable portion of the inner part of the 
epiphyseal line, and its apex approaches the intercon- 
dyloid notch. After the removal of the wedge of bone 



277 

the inner condyle is folded back against the shaft. The 
objections to this operation are, that it is difficult to 
perform ; that it is difficult to estimate the necessary 
thickness of the base of the wedge ; and that arrest of 
growth sometimes results from the injury to the epiphy- 
seal line. 

Macewen's operation divides the femur above the 
condyles by means of an osteotome. The Macewen 
osteotome is an instrument of the chisel order, beveled 
on both sides so as to resemble a slender wedge. The 
handle and blade form one piece. The handle is oc- 
tagonal. At the top of .the instrument is a rounded 
projecting head. One of the surfaces of the blade is 
marked in half inches. The whole instrument is finely 
burnished. The apex of the wedge ends in a cutting 
edge ground beveled to the sides of the blade like the 
cutting edge of a pocket-knife. Indeed, the blade of 
the osteotome closely resembles the cross-section of the 
blade of such a knife. A razor-edge does not have this 
second bevel, and the osteotome does not have the 
razor-edge, but the cutting-edge must be sufficiently 
sharp to pare the finger-nail. 

The instrument is made from the finest Stubbs' steel, 
forged at a low heat, and tempered between a carpen- 
ter's tool and an iron-worker's tool. An inch of the 
tip is brought to a finer temper than the remainder of 
the blade. If there is any doubt about the temper it 
should be tested on a hard ox bone ; the edge must 
neither turn nor chip. A set of osteotomes usually 
comprises three, the blades being of different thick- 
nesses. The thicker instrument is always used first, 
followed by a thinner one when necessary. The oste- 
otome is driven into the bone by a heavy mallet. 
Macewen prefers one of lignum vitae. 

The patient must be profoundly anesthetized lest 
any movement of the muscles produce a larger wound 



278 

than necessar}^ The limb is rendered bloodless by an 
Esmarch bandage. INlacewen prefers to use the band- 
age as a constrictor instead of the elastic cord. The 
limb is placed upon a sand-pillow. The pillow is 12 
by 18 inches, and only moderately filled with sand, 
so that the limb can be embedded in it. The pillow 
is moistened before the operation to prevent dust aris- 
ing and to render the sand more cohesive. The point 
for the incision of the soft parts is on the inner side of 
the thigh, half an inch in front of the adductor magnus 
and on a level with a line drawn transversely across the 
thigh a finger's breadth above the upper border of the 
external condyle. The incision in the soft parts must 
be made parallel with the long axis of the thigh, and 
ought to be a sharp, clean, single incision, produced by 
one stroke of a good-sized scalpel. It is not desired 
that the knife divide the periosteum. Before the knife 
is removed the osteotome is introduced. After the re- 
moval of the knife the cutting-edge of the osteotome is 
turned transversely across the bone. The handle of the 
osteotome is grasped by the left hand of the operator, 
his thumb underneath the head of the instrument and 
the ulnar surface of his hand, or of his wrist, resting on 
the limb. The cutting-edge is brought in contact with 
the posterior border of the inner surface of the bone 
and directed towards the outer and anterior border, and 
in this direction driven through the inner hard portion 
of the bone, the soft portion, and up to the outer hard 
portion. After each blow of the mallet the osteotome 
is lifted slightly by the hand which grasps it so that it 
does not become firmly wedged into the bone. This 
lifting is not done by swaying the instrument from side 
to side, but by grasping it close to the limb, and swell- 
ing the muscles on the ulnar side of the hand against 
the limb. If it cannot be made to penetrate sufiiciently 
far without wedging it should be replaced by a thinner 



279 

tool. When the bone has been penetrated sufficiently 
far in the direction indicated, a second entrance is made 
from the anterior border of the inner side of the bone, 
with the cutting-edge directed outwards and backwards. 
In this manner the popliteal artery behind and the pro- 
longation of the synovial sac in front are not endan- 
gered. When sufficient bone has been cut the remain- 
der is broken by bending the limb in the direction of 
correcting the knockknee. In young subjects the limb 
is bent slowly with the intention of producing a green- 
stick fracture ; in older and harder bones it is snapped 
by a sudden blow-like bend. 

The wound is dressed without drainage. Macewen 
closes it with a small piece of carbolized Lister protec- 
tive ; others use carbolized rubber tissue ; and others 
seal the wound with collodion and cotton or gauze, after 
taking two or three superficial stitches. In either case 
an aseptic dressing is placed around the limb for a 
considerable distance above and below, and the frac- 
ture immobilized in a plaster-of-paris spica or a back- 
and-side board splint. 

After the patient has recovered from the anesthetic 
the surgeon must assure himself that the circulation, 
the sensation, and the motion in the toes are normal. 
At the end of a fortnight it will usually be found that 
the wound has healed, and the antiseptic dressings can 
be removed. Immobilization of the fracture must be 
continued, however, until union is perfect. 

Macewen believes that the advantages of the opera- 
tion are that no bone is removed ; that both sides of the 
bone contribute to rectify the deformity, one being 
compressed while the other stretches, or gaps with the 
periosteum preserved over the gap. The operation is 
much more frequently chosen by surgeons generally 
than any other cutting operation and in bilateral cases 
is undoubtedly the best. 



280 

Adolescent Rickets: Adolescent rickets has generally 
been considered as identical in its characteristics with 
infantile rickets. Our observation is not in accord with 
these views ; nor with the opinion that it is found only 
during the period of adolescence The so-called rachitic 
deformities of adolescence that we have observed are 
bowlegs, knockknees, and coxa vara. In the adole- 
scent bowlegs that we have seen the deformity is con- 
fined to the proximal end of the leg bones and is usu- 
ally unilateral; whereas infantile rickets shows the 
deformity in any part of the leg bones in the following 
order of frequency : in the lower third ; in the lower 
third and the upper third about equally ; in the upper 
third alone; in the shaft; and the deformity is usually 
bilateral. The adolescent bowleg is then more strictly 
an outknee, the opposite of inknee (knockknee), than a. 
true bowleg. The difference in the bony deformity 
between the adolescent and the infantile forms may be 
seen in the Rontgen pictures of these two deformities. 
Adolescent knockknees do not show the peculiarities- 
equally well. The deformity seems to begin in the 
upper end of the tibia, but as soon as any deformity 
has developed the line of gravity falls too far to the 
outer side of the joint, the inner lateral ligaments 
stretch, the line of gravity goes farther out, weight i& 
carried on the outer femoral condyle and its growth is 
retarded while the inner condyle relieved from weight- 
bearing grows abnormally long. Similar changes take 
place in the articular surface of the tibia. Coxa vara 
consists of a change in the relation of the head of the 
femur to the shaft of that bone. The head gradually 
sinks to or below the level of the greater trochanter 
and nearer to the shaft of the bone. In some cases the 
femoral neck seems to bend, while in others it seems 
to actually disappear to a very considerable extent and 
the globular head may appear to lie against the inner 



282 



surface of the upper end of the shaft of the bone. At 
times the trochanteric region appears thickened. The 
process is usually a gradual one and is unaccompanied 
with pain or any special sensitiveness. 

The main characteristics of this so-called adolescent 
rickets are: The condition appears somewhat later 
than the usual period of infantile rickets, and in chil- 




>^^4V 




"^ 



Fig. 228.— Showing range of flexion in the boy with coxa vara. The first case 
here reported. 

dren who have had a healthy infancy ; it is more often 
than otherwise unilateral and confined to the proximal 
ends of the long bones ; it is not accompanied by the 
usual symptoms and signs of infantile rickets, such as 
enlarged wrists and ankles, enlarged abdomen, deformed 
chest, square head, etc.; it progresses for several 
months, or even for 2 or 3 years, when the progress 



283 



ceases and the deformities thenceforth remain un- 
changed. Correction of the deformity after the pro- 
gress has ceased gives permanent results; correction 
before this time is usually followed by a return of the 
deformity. A traumatism occurring during the jDro- 
gress of the deformity may render the bone-end sensi- 
tive for some weeks and make a differential diagnosis 
from tubercular joint-disease somewhat difficult. It is 
only by a careful consideration of the history of the 




Fig. 229. — Showing the range of extension in the boy with coxa vara. The first 
case here reported. 



case and the essential diagnostic symptoms of tubercu- 
lar disease that one may be reasonably sure. The Ront- 
gen picture may help very materially, but observation 
for some weeks may be required to render a conclusive 
opinion. The diagnosis of coxa vara is of course more 
difficult than that of bowlegs and knockknees. The 
following cases will illustrate that difficulty : 

A boy, 5 years old, the second of three healthy 



284 

children of healthy parents, was noticed limping slightly 
in January, 1896. He had always been well and was 
an unusually active and robust child. There was no 
complaint of pain and no disability except the slight 
limp. Examination showed |- inch shortening of the 
limb measured from the anterior superior spine of the 
ilium to the inner malleolus ; no shortening measured 
from the tip of the greater trochanter to the outer mal- 
leolus ; and upward displacement of the greater tro- 
chanter equal to the amount of the shortening. There 
was no restriction to motion in any direction. From 
this time on we measured the limb once or twice each 
month for 6 months and the ^ inch shortening gradu- 
ally increased to f inch. There were no other symp- 
toms. The diagnosis was coxa vara ; and this was con- 
firmed by Dr. L. L. McArthur, of Chicago. 

In June, 1896, the patient went to Yonkers, New 
York, where he amused himself by repeatedly jumping 
down three or four steps to a stone walk. Soon the 
limp increased and motion at the joint became some- 
what restricted. He was examined by Drs. Newton M. 
Shaffer, Virgil P. Gibney, and Royal Whitman, of New 
York. 

Dr. Shaffer regarded the case as one of chronic dis- 
ease of the head, neck, and acetabulum. 

Dr. Gibney believed it to be a bending of the neck of 
the femur. 

Dr. Whitman was inclined to believe it was a tuber- 
culosis of the neck of the femur. 

The boy was at once returned to our care. We found 
much the same symptoms as were recorded by Drs. 
Gibney and Whitman. Our previous observation of 
the case, however, led us to doubt the conclusions of 
the New York surgeons in so far as the question of 
tuberculosis was concerned and to hold to the previous 
diagnosis of coxa vara. Nevertheless, as a precaution 



t 



285 

against error on our part a long traction hip-splint of 
the pattern approved by Dr. Shalfer was applied, this 
also acting as a perineal crutch and protection to the 
joint as advised by Drs. Gibney and Whitman. Within 
6 weeks all restriction to the normal range of motion 
had disappeared and the boy was in precisely the same 
condition as before going to New York. From this 
time on there was no change except that the muscles of 
the leg were less well-developed than those of the other 
leg. 

About 7 months later Drs. Shaffer and Whitman 
again examined the patient. 

Dr. Shaffer was confirmed in the opinion that the 
boy had a tuberculous hip. 

Dr. Whitman was in doubt as to the pathologic pro- 
cess that caused the bending of the femoral neck. 

The condition of affairs remained unchanged. In 
May, 1897, after having worn for eleven months the 
long traction hip-splint, commonly employed to im- 
mobilize and protect in tuberculous arthritis of the hip- 
joint, photographs were made to demonstrate the range 
of motion at the joint in flexion and extension. Fig. 
228 shows the boy easily able to flex the limb, held 
straight at the knee, so that the foot approaches the ear, 
Fig. 229 shows equally full hyperextension. One would 
hardly expect to find so free a range of motion in a 
healthy joint after having been constantly confined in 
a long traction hip-splint for eleven months, and it 
positively excludes the presence of tuberculosis in or 
near the joint, or its existence in those parts at any 
previous period. The condition of affairs remaining 
unchanged at the end of two years, the shortening be- 
ing f inch, the adhesive plasters used in making trac- 
tion were dispensed with, but the splint was continued 
— used only as a perineal crutch. Three years from 
the beginning of the observation, in January, 1899, the 




"3 '^ 



Z.'^ 



-2 * 



5s 



288 

perineal crutch was put aside. When last examined, 
in May, 1899, the condition was unchanged. 

E H , male, 12 years old, was first seen by us on February 
1, 1897. The family history is free from tuberculosis and 
rickets. The patient never had aoy special or serious sick- 
ness. When about 7 years old it was noticed that he 
limped and stepped on the toe of his right foot. About a 
year and a half later, when 8j years old, he was examined 
by Dr. jSTicholas Senn, of Chicago The mother, an intelli- 
gent woman, thinks there was some question as to the diag- 
nosis, but she was told that it was incipient hip-disease. 
She is sure that there was no difference in the measurements 
of the two legs at that time. Slie was instructed as to the 
treatment, which was weight-and-pulley traction at night, 
but was told to let the boy continue out of-door exercise 
during the days. Xo brace was applied. Later on the boy 
was circumcised. 

Six months ago the mother first noticed outward bowing 
at the right knee, and that he leaned to the right in walk- 
ing. There had never been any pain or tenderness, or night 
cries. The patient stands with the right knee sUghtly 
flexed and bowed outward, and the right hip somewhat 
lower than the left. The thigh can be flexed to a right 
angle ; rotation is very normal ; adduction normal, abduc- 
tion more than half the normal extent ; hyperextension 
normal. There was no muscular spasm, and the restriction 
to motion appeared to be bony. Measured, anterior supe- 
rior spine of ilium to inner malleolus, 1 inch shorten' ng ; 
from tip of greater trochanter to external condyle of femur, 
no shortening : from tip of internal condyle to inner malle- 
olus, J inch shortening. The circumference of the right 
thigh was f inch less than the left, and the right ca f ^ inch 
less than the left 

The Rontgen photograph, Fig. 230, shows the condi- 
tion of affairs at the hip. The head of the femur is 
depressed; the neck shortened; and the trochanteric 
region thickened and somewhat lessened in density. 
There does not appear any evidence of present or past 
disease of the hip-joint itself. Fig. 231 shows the condi- 
tion of affairs at the knee. The upper end of the tibia 
is thickened ; less dense ; has irregular notches and 
projections at the sides, and three transverse lines 
somewhat resembling the single lines that appear at 
the epiphyseal junctions of bones in young children. 



289 

A comparison of these pictures with the Kontgen pic- 
tures of ordinary infantile rickets demonstrates the 
marked difference that exists between the two con- 
ditions. 




Fig. 232. — Adolescent rickets, showing knockknee. The patient holds a Thomas 
knockknee brace in his left hand. 



When much thickening takes place in the bone ends^ 
whether at the hip or knee, but more especially at the 
hip, the range of motion will be diminished to some 
extent. At the hip, abduction is restricted more than 



290 



the other motions, and next to abduction rotation is 
restricted. 

Treatment during the progress of the disease may, 
and probably does, lessen the amount of deformity. At 
the knee, braces should be applied in the same way as 




i&^ 




Fig. 233.— Adolescent rickets, showing the Thomas knockknee brace applied. 



in the treatment of the same deformity in infantile 
rickets ; at the hip, support should be given by some 
form of perineal crutch to relieve the femoral neck, 
weakened by disease and at a disadvantage from its 



291 

right-angled position, from weight-bearing. When the 
disease has ended, the deformity at the knee can be 
corrected by osteoclasis or osteotomy as infantile rick- 
ets. The true shortening from coxa vara may be only 
partially corrected by osteotomy in the trochanteric 
region, but the false shortening from adduction and 
flexion can be fully corrected. The operation is pre- 
cisely the same as that performed for the correction of 
adduction deformity resulting from hip- disease. 



CLUBFOOT. 

Clubfoot, talipes, is a deformity of the foot, consist- 
ing mainly of a distortion of the bones of the tarsus 
and of the foot as a whole in its relation to the leg. 
The simple varieties of talipes are equinus and cal- 
caneus, varus and valgus ; the compound varieties are 
equinovarus, equinovalgus, calcaneovarus and calcaneo- 
valgus. These deformities may be either congenital or 
acquired, and when acquired are usually the result of 
infantile paralysis. Another deformity of the foot due 
to paralysis is cavus, or pes cavus as it is more often 
called. Still another acquired form is planus, or pes 
planus, due to inherent weakness in the foot, or to ex- 
cessive or long- continued weight-bearing. The paralytic 
deformities, and those due to weakness, will be consid- 
ered under another heading. 

In talipes equinus the foot is plantar flexed, i. e., ex- 
tended on the leg, without lateral deformity, and can 
not be dorsal flexed. Calcaneus is the opposite de- 
formity, the foot being dorsal flexed and the heel 
presenting, the patient being unable to extend the foot 
on the leg. In varus the foot is shortened in all its 
structures on its inner surface, and is both inverted and 
rotated inward from its normal relations to the leg. In 
valgus the foot is everted and rotated outward in its 
relations to the leg. The compound varieties present 
combinations of the above-mentioned deformities. 

Nearly all the cases of congenital clubfoot present 
the compound variety — equinovarus. The foot is ex- 
tended and the heel is drawn up ; the foot as a whole 
is rotated inward and inverted, but the front portion of 
the foot consisting of the metatarsus and phalanges is 
bent further inward and is more inverted than the 



293 



tarsal portion of the foot. In severe cases the sole is 
shifted from the horizontal to the vertical plane and 
looks inwards and backwards, or directly backwards. 
A few cases present the equinovalgus deformity. 
Simple calcaneus is exceedingly rare ; and simple 
equinus is still more rare. We have not seen simple 
varus (that is, varus without equinus) nor simple val- 
gus. In the writings of the older surgeons frequent 
mention is made of " talipes varus," but it is the vari- 




FiG. 234.— Unilateral congenital 
eqainovarus. 



Fig. 235.— Congenital eqainovarus 
of marked degree. 



ety now known as equinovarus and not simple varus 
that is meant. 

Congenital clubfoot is not of frequent occurrence. 
Lannelongue found only 8 children born with clubfoot 
in over 15,000 births, or about one in 1,900. 

The etiology of clubfoot has been much befogged 
by numerous and conflicting theories. At least 5 have 
had the backing of the best men in the profession. 
These theories are: 

1. The paralytic theory, which received the support 



294 

of William J. Little, the father of orthopedic surgery 
in England. Because of the similarity between the 
congenital and the acquired forms it was assumed that 
congenital deformities were due to the same nerve- 
lesions that produced acquired clubfoot. Microscopic 
examination, however, does not reveal the changes in 
the brain and cord in cases of congenital clubfoot that 




Fig. 236. — Bilateral congenital equinovarus. Deformity increased from walking 
in the deformed position. 

are demonstrable when distorted feet are due to in- 
fantile cerebral and infantile spinal paralysis. The elec- 
trical reactions are not changed from the normal, and the 
voluntary motion, the color and temperature of the skin 
and the muscles are quite different from what is found 
in paralytic clubfoot. 

Further, paralytic clubfoot is the result of years of 



295 



malposition, no case becoming really deformed in so 
short a period as nine months. In offering the above 
objections to the paralytic theory we do not mean to 
say that a case of paralytic clubfoot which has been 
present from birth may not have antedated birth. We 




Fig. 2 j7. — Congenital equinovarus before treatment. 

believe that we have seen one such case: A girl of 9 years, 
the only child of educated and observing people. The 
deformity was described as a typical double equino- 
varus, and was present at birth. It had been treated 



296 

much of the time for the nine years by braces, manip- 
ulation and massage. No operation had been per- 
formed, and the parents had been warned against an 
operation by the late Dr. Roth, of London, in whose 
care the child was for some time. When we saw the 
case, the appearance of the feet was much as one would 
expect in a severe congenital case treated as this had 
been. The varus had been almost wholly corrected, 
but the front of the foot was abnormally broad ; the 
foot, however, could be inverted and the head of the 
astragalus made prominent. A marked degree of 
equinus was present, indeed the feet could not be ex- 
tended (plantar flexed) beyond the point where they 
were habitually held, and dorsal flexion could be de- 
monstrated only to a very slight extent and when con- 
siderable force was used. The tip of the os calcis, for 
the attachment of the tendo-Achillis, was markedly 
prominent and displaced far inward ; the skin and local 
temperature appeared to be normal ; the electric reac- 
tions were not tested. It was assumed that it was a 
congenital case of the usual type and that the anterior 
leg muscles would rapidly regain their normal contract- 
ility and strength when relieved of strain and relaxed. 
To this end the tendo-Achillis was cut on both legs and 
the posterior ligaments of the ankle-joints ruptured 
so that the dorsal flexion of the feet was perfect. Now 
at the end of 5^ years, although the feet have been 
retained in the normal position, there has been no 
return of voluntary muscular control and no gain in 
voluntary dorsal flexion. 

2. The second theory is that of abnormal (excessive) 
uterine pressure. This theory has been supported by 
most of the older writers and such prominent modern 
surgeons as Volkmann, Kocher, and Vogt, in Germany, 
and R. W. Parker, in England. The objections to this 
theorv are that clubfoot is often found in instances 



297 

when there is known to have been an abundance ot 
amniotic fluid, and absent when the amniotic fluid was 
scant ; in fact, that it bears no relation to the quantity 
of fluid ; that twins have been born, one with, and one 
without, clubfoot ; that there are hardly any other con- 






FiOr. 238.— Same case after treatment. 



genital deformities that could be accounted for by ex- 
cessive uterine pressure ; and that the frequency of the 
equinovarus deformity and the infrequency of other 
clubfoot deformities is not accounted for by the theory. 



298 

3. The third theory is the opposite of the last, namely, 
it is the theory of the lack of normal uterine pressure. 
This was advanced by Luecke, who called attention to 
the fact that very many fetuses at some early period of 
their development present a greater or less degree of in- 
version of the feet and that this diminishes as full term 
approaches. He held that the lack of a foothold, so to 
speak, against which to kick in those cases where an 
excessive amount of amniotic fluid was present resulted 
in the feet remaining in the equinovarus position. 





Fig. 239 —Normal astragalus. Showing 
relation of axis of neck to the tibial 
articular surface. 



Fig. 240. — Deformed astragalus from a 
case of congenital equinovarus. 
Showing distortion of neck in rela- 
tion to tibial articular surface. 



This theory was developed and carried to its logical 
sequences by H. W. Berg, of New York. He says : 
" As soon as the joints are formed we find the thigh 
rotated out as far as possible, and flexed upon the body. 
The leg is flexed upon the thigh, but not completely, 
for this is prevented by the extreme rotation of the 
thigh which brings the inner border of the leg pressed 
against the abdomen of the fetus, the legs crossing each 



299 

other a little below the middle. All the intrauterine 
pressure, therefore, is brought to bear directly upon the 
outer border of the leg and thigh, and also upon the 
dorsum of the foot. The result of this is that the foot 
is rotated in and extended (equinovarus) until the sole 




Fig. 241. 



-The drawing on the right shows the inward distortion of the bones of 
the tarsus in congenital equinovarus. 



is almost on a line with the inner border of the leg, and 
lies against the body of the fetus, while the dorsal sur- 
face of the foot is on a convex curved line with the 
outer border of the leg, to adapt itself to the concave 
wall of the uterus. This, I believe, is a stage in the 



300 



normal development of every healthy fetus ; and were 
the extremities to remain in this position, all children 
would be born clubfooted. But nature provided against 
this by the outward rotation of the extremity, which 
gradually takes place, carrying the leg away from the 
position against the abdomen of the fetus ; and when 
this rotation is completed we find the extensor surface 
of the thigh flexed and in relation to the body of the 




Fig. 242.— Unilateral congenital equino- 
varus after treatment. Some varus 
deformity still remaining. 



child, 



Fig. 243.— Intoe deformity remaining 
afier correction of theantero-pos- 
terior (equinus) deformity and 
the lateral (varus) deformity. 



., while the legs are flexed upon the thighs, the 
inner or tibial borders facing each other. Now the 
soles of the feet lie against the uterine walls, and the in- 
trauterine pressure is exerted directly upon them. This 
produced extreme flexion of the foot upon the leg, to- 
gether with an outward rotation of the foot ; this move- 



301 



ment, from the constitution of the ankle-joint, 
accompanying extreme flexion. Thus is antagonized 
the varus or equinovarus existing hitherto. It is evi- 
dent, then, that upon the completeness of the internal 
rotation or torsion which takes place in the lower 
extremity, depends the rectification of the early varus 
of the foot. Sould this rotation not take place at all, or 
be incomplete, the foot will continue to maintain its 
early relation to the body 
of the fetus and uterine 
walls, and the child will 
be borne more or less 
clubfooted. If this is so, 
we should expect to find 
in clubfooted children 
that the extremities are 
rotated outward. And 
this we do find upon ex- 
amination. In all of the 
cases of congenital club- 
foot (equinovarus) which 
I had seen since my at- 
tention has been directed 
to this subject, I have 
found that the thigh and 
leg, as a whole, were ro- 
tated out, and the tibia 
bent at its lower part, so 
that the feet are approxi- 
mated to each other in addition to being in the clubbed 
position. All this is seen to be the result of nonrotation 
of the leg." 

The chief fault in Berg's theory is that it only accounts 
for equinovarus ; and does not account for congenital 
calcaneovalgus and congenital clubbed hands which we 
have seen in a patient suffering from congenital equino- 




FiG. 244.— Imprint of a normal foot. 



302 



varus. It is probable that at the time Berg wrote his 
paper he had never seen any other form of congenital 
clubfoot. 

4. The fourth theory, advanced by Professor Esch- 
richt, of Copenhagen, in 1851, is that of arrest of 
development. It is based on the observation that club- 
foot deformities, like such other congenital deformities, 
as clubhands, webbed, supernumerary, and deficient 

fingers and toes, constric- 
tion bands, amputations 
and deficient members 
and parts of members, 
harelip, cleft -palate, 
spina bifida, acephalus 
and other monstrosities, 
more frequently are 
found in males than 
females, more frequently 
in children born out of 
wedlock and in those 
whose mothers have had 
unusual worry and anxi- 
ety than otherwise ; and 
more frequently in first 
children than those born 
at a later period. In sup- 
port of the above, innum- 
^ „_ , . , ^ , erable instances have 

Fig. 24o.— Imprmt of a foot tending to re- 
lapse from obliquity of the anterior bcCU obscrved and rC- 
articular surface of the os calcis after 

correction of the equinovarus de- COrdcd ; an CQUal number 
formity. ' ^ 

have been observed con- 
troverting the theory. The following illustrates the 
point : Some years ago in New York a widower, the 
father of 3 normal children, met and married a widow, 
the mother of 2 normal children. There was no hered- 
itary deformity in either family and these two, man 




3C3 

and wife, were in no way related by consanguinity, but 
the result of the union was 3 children, all with double 
talipes equinovarus. This instance would appear to 
controvert each of the foregoing theories. 

5. The fifth theory is that of heredity, in support of 
which the account of a French shoemaker, to be found in 
Valentine Mott's edition of Velpeau's " Surgery," trans- 
lated by Townsend, may be related. It seems that the 
worthy shoemaker had double talipes varus, and his 
first four children all had double talipes varus, but the 
fifth child was born with normal feet. The shoemaker 
accused his wife. Arguments against heredity do not 
need to be advanced, for cases like the above are too 
infrequent to demand an extended argument. 

In considering all of these theories the only con- 
clusions that can be reached are that an individual 
case of clubfoot may be accounted for by any one, or 
by several, or by none of these theories, and that in most 
instances we do not know what causes the deformity. 

As to the anatomy, we have seen neither dissections 
nor descriptions of the anatomy of congenital equinus 
or valgus. 

R. W. Parker reports two cases of congenital calcaneus 
in which the tendons of the tibialis anticus and extensor 
proprius hallucis and the anterior ligament of the ankle 
had to be divided before the foot could be fully ex- 
tended. In these cases the only change in the bones 
was in the upper facet of the astragalus, which was 
displaced somewhat forward. 

In acquired deformities of the feet the change con- 
sists only in those alterations of the articular surfaces 
that arise from the malpositions, and such bony changes 
as are due to growth in the malpositions. We may then 
limit our consideration to the changes occurring in con- 
genital equinovarus. These cases differ somewhat, in- 
asmuch as the distortion differs in degree in difierent 



304 

cases, and description of writers vary somewhat depend- 
ing upon the case, or cases, dissected by them. 

To Dr. Frank Hartley, of New York, we are indebted 
for the following description of a congenital case of 22 
years' standing, the position being that of extreme 
equinovarus : 

There was a large multilocular bursa covering the 
bearing points of pressure over the anterior process 
of the calcaneus and the dorsolateral surface of the 
cuboideus, and a smaller multilocular bursa covering 
the neck of the astragalus and the lower portion of the 
external malleolus. 

The anterior annular ligament was thick and strong. 
The external annular ligament consisted of a firm, 
broad band covering the peroneal tendons as they 
passed to the posterior surface of the calcaneus. The 
internal annular ligament was well marked but very 
short. The muscles in the leg and foot were atrophied 
and had the following relations : The tibialis anticus 
passed over the lower third of the tibia, from without 
inward, to the inner surface of the internal malleolus, 
whence it descended to its insertion. The extensor 
proprius pollicis passed through a separate compart- 
ment of the annular ligament over the inner surface 
of the internal malleolus, close to and in front of the 
tibialis anticus. It divided into two tendons which 
were inserted in the second phalanx. 

The extensor longus digitorum passed over the outer 
third of the anterior surface of the tibia, in a groove 
bounded by two well marked prominences. It was 
covered by the annular ligament. It divided into four 
tendons, which passed obliquely inward over the heads 
of the first and second metatarsal bones to the four toes. 

The peroneus tertius passed obliquely outward to the 
base of the fifth metatarsal bone over the cuneiform 
bones. The extensor brevis digitorum was scarcely 
observable except for its tendons. 



805 

The peroneus longus and brevis passed beneath a 
strong and narrow band of fascia, extending from the 
external malleolus to the calcaneus, and representing the 
external annular ligament, around the external and 
posterior surface of the calcaneus to their insertions. 
The former did not touch the cuboid bones. It passed 
above the level of the anterior processes of the cal- 
caneus obliquely, directed from without downward and 
inward. The latter after passing over the anterior pro- 
cess of the calcaneus, descended upon the lateral border 
of the cuboid bone to its insertion. 

The tibialis posticus passed to the inner side of the 
internal malleolus, its posterior border beneath it, and 
to its insertion. 

The flexor longus digitorum passed to the outer side 
of the tibialis posticus, beneath the internal malleolus^ 
to its insertion. 

The flexor longus pollicis passed through a well marked 
groove in the tibia, external to the flexor longus digit- 
orum, beneath the internal malleolus, and was lost in 
the muscles of the foot. The relations of the bones of 
the foot to one another and to those of the leg, were in 
general as follows: 

The position of the calcaneus was one of marked 
plantar flexion. Its long axis formed with the articu- 
lar surface of the tibia an angle of 80°, which amounts 
to 41° of forced plantar flexion of the foot. Further, the 
bone was supinated 50°, and adducted about 10°. Be- 
sides the articular surface for the astragalus, there was 
upon this surface, just in front of the tuberosity, near- 
throses for both the tibia and fibula. That for the 
former was continuous with the external third of the 
articular surface for the astragalus, and was situated 
upon the superior (really internal) surface. That for 
the latter was situated upon the external (really su- 
perior) surface. 



306 

The anterior process of the calcaneus was large and 
prominent. Situated upon the internal surface of the 
neck of the calcaneus was the articulation for the 
cuboid. 

The astragalus was situated in the angle formed by 
the bones of the leg and the calcaneus. Its superior 
surface articulated with the tibia, and was external so 
far posterior as to be continuous with the inferior 
articular surface in its outer half of the same surface 
by a 5 mm. strip of nonarticular bone. 

The shape of the body was triangular with the apex 
posterior, and with the surface looking upward and the 
inferior surface looking downward and backward. The 
neck of the astragalus formed with the body an angle 
of 45° for the inward displacement, and of 90° for the 
downward displacement. Upon the internal surface of 
the neck is an oval facet for articulation with the 
scaphoid bone, the long axis of which is placed at an 
angle of 45° to the long axis of the neck. 

The scaphoid bone articulates with the neck of the 
astragalus only in the external portion of its superior 
surface ; with the internal portion of the same surface 
it is nonarticular and is bent sharply upon the outer 
segment. The long (that is, transverse) axis of the 
scaphoid is nearly parallel with that of the neck of the 
astragalus. The bone presents two nearthroses. One 
for the anterior surface of the sustentaculum tali ; the 
other for the internal malleolus at its anterior and in- 
ferior angle. The superior (anterior) surface was 
broad. The inferior was narrow. The external was 
narrower than the internal. There was no tuberosity 
present, nor did the bone articulate with the cuboid. 
The transverse axis formed with the transverse axis of 
the cuboid an angle of 90°. 

The cuboid bone articulated with the anterior pro- 
cess (that is, neck) of the calcaneus upon its internal 



807 

surface, in such a manner that the weight of the body 
was in part sustained by the dorsolateral surface. 
There was no sulcus for the peroneus longus tendon, 
nor was the tuberosity present. The three cuneiform 
bones articulated with the scaphoid and cuboid in the 
angle formed by them. Their position was one of 
marked supination, adduction, and approximation of 
the inner and outer bones toward the plantar surface. 

The tibia and fibula were rotated inward about this 
long axis with the external malleolus anterior to the 
internal. Upon the fibular malleolus were two facets, 
one for the astragalus and one (a nearthrosis) for the 
calcaneus. These were separated by a nonarticular 
surface. Upon the tibial malleolus were three articular 
facets, one for the astragalus, and one (a nearthrosis) for 
the scaphoid, and one (a nearthrosis) for the internal 
cuneiform. 

For comparison with Hartley's adult case, we will 
review the findings of R. W. Parker, of London, Eng- 
land, in a patient of 18 months, who died of tuberculous 
meningitis. 

The spinal cord was normal to the eye and on micro- 
scopic examination; as was also the popliteal nerve 
and its main divisions. Portions of each muscle of the 
leg were examined microscopically and found to be 
perfectly healthy. The anterior portion of the internal 
lateral ligament of the ankle-joint was firmly blended 
with the astragaloscaphoid ligament above, and the 
calcaneoscaphoid ligament below, and all were short- 
ened. A bursa was found between the tip of the mal- 
leolus and the scaphoid bone. The upper articular 
surface of the astragalus extended backward as far as 
the posterior surface of the lower articular surface. 
The neck of the astragalus was elongated and its obli- 
quity amounted to 53°, as against 38° in the normal 
bone. The articular surface of the head was pro- 



longed to the inner side. The internal malleolar facet 
was not recognized. The calcaneus was rotated in- 
ward beneath the astragalus and a considerable por- 
tion of the upper posterior facet was uncovered and ar- 
ticulated with the posterior border of the external mal- 
leolus. The plane of the cuboidal facet was directed 
unnaturally inward. 

The symptoms of congenital club-foot are the evi- 
dent deformity, the restricted range of motion, a certain 
amount of muscular atrophy from disuse, and callosi- 
ties from weight-bearing in an unnatural position. 

The diagnosis of congenital clubfoot presents no 
difficulties, providing the history can be relied upon, 
except as to the anatomic relations and the consequent 
choice of treatment. Paralytic cases and at times 
hysterical cases present much the same appearance as 
congenital cases, but the history generally clears up 
the diagnosis at once. 

The prognosis depends upon the degree of deformity 
and upon the treatment. Without treatment congenital 
cases grow progressively worse. With sufficiently pro- 
longed mechanical support and such operations as the 
gravity of the case demands all deformities may be made 
right and the patient enabled to walk upon the soles of 
his feet. Improved muscular strength and muscular de- 
velopment are the natural result of use when once the 
deformities have been corrected. Clubfoot has no effect 
upon the general health and does not endanger life. 

The treatment of clubfoot is mechanical, or operative, 
or both mechanical and operative. The earliest record 
that we have is that of the treatment employed by Hip- 
pocrates and consisted of bandaging and the use of a 
leaden shoe. 

The first mechanical device intended to have a posi- 
tive corrective action of which we have record is the 
" shoe " of Scarpa, of Pavia, in 1803, from which all 



309 

later shoes and braces for the treatment of this deformity 
are hardly more than modifications. The aim of all 
bandaging and brace treatment is to maintain the foot 
in a somewhat corrected position, and to gradually gain 
something upon this position by the exercise of so 
much of a corrective force as can be borne without 
serious discomfort or injury to the soft parts. Braces, 
bandaging, and the various retentive dressings are us6d 




Fig. 246.— Hand stretching of eqiiinovarus during infancy. 

either alone or in conjunction with various operative 
procedures. 

The simplest and most frequently used of the reten- 
tive dressings is the plaster- of-paris bandage. Plaster- 
of-paris was first used in these cases by Jules Guerin, of 
Paris, in 1826. He braced the foot in the best position 
possible and poured liquid plaster around it. The 
plaster bandage is of much more recent date. It is 



310 

used as a retentive dressing after hand-stretching and 
wrenching, and after any of the cutting operations to 
be mentioned hereafter. Narrow bandages from two to 
three inches wide are the best. They may be applied 
directly over the well greased foot, or over the foot 
wrapped with cotton or with bandages made from sheet- 
wadding. The most convenient covering, however, is a 
smoothly fitting stocking. The plaster bandage should 
be wrapped from within under the foot and outward so 
that at each turn the foot is drawn somewhat in the 
direction of correction of the deformity. When finished 




Fig. 247. — Hand-stretching of equinovariis in Infancy. 



the plaster splint should reach from the base of the toes 
to the garter line, and the foot must be held in the de- 
sired position until the plaster sets. The toes should 
be left exposed for an index that the limb has not been 
injuriously constricted. When used as a retentive dress- 
ing to hand-stretching or wrenching the plaster splint 
should be renewed every few days. When used after a 
cutting operation it is usually left on until the wound 
has healed and some more conveniervt retention device 
has been applied. In infants the plaster splint will be 



312 

found a satisfactory dressing up to the time when the 
child attempts to walk, when a retention-splint having 
a flat.sole and permitting of dorsal flexion at the ankle- 
joint will be required. 

Barwell's dressing consists of a broad piece of adhe- 
sive plaster passed around the foot, from the dorsum 
around the inner margin of the front portion of the 
foot under the sole and up on the outer margin ; this is 
connected by an elastic accumulator with a hook on 
the anterior and outer side of the shin at the garter 
line. The hook is usually made fast in its place by 
adhesive plaster. There are various modifications of 
this dressing, the more common being the use of two 
narrow strips of plaster instead of one passed around 
the foot and carried up the shin where they are made 
fast, and the whole covered by a roller-bandage. 

Taylor's shoe consists of a foot-piece of sheet-steel 
made after a pattern of the sole of the foot, with a flange 
turned up against the inner margin. This flange reaches 
to the tip of the inner malleolus at the back and slopes 
forward a little below the level of the dorsum of the 
foot. The foot is held firmly in this foot-plate by 
various webbing straps and by adhesive plaster applied 
to the leg and passing down to a buckle at the upper 
and posterior angle of the flange of the foot-piece. The 
leverage for overcoming the varus is had by a leg-piece 
hinged to the foot-piece by a single rivet, and passing 
up the inner side of the leg to the garter line, where it 
terminates in a band encircling the leg. This band is 
of leather excepting that third which lies to the inner 
side of the leg, which is of sheet- steel. A similar band 
passes around the ankle. Just in front of the junction 
of the leg-piece with the foot-piece is placed a set-screw 
which limits the movement between the leg-piece and 
the foot-piece, permitting the foot to be dorsal flexed 
or the leg-piece to be carried forward, but not permit- 



313 



ling the opposite movements. This brace is the most 
satisfactory of the continuous leverage braces, but it 
requires constant attention on the part of the surgeon 
to be at all useful. 

Intermittent machine-stretching and continuous re- 
tention is best illustrated by Shaffer's 
shoes. In equinovarus the lateral de- 
formity is treated first. Some years 
ago Shafi'er used a shoe consisting of a 
sheet-steel foot-plate hinged obliquely 
at the ankle to a sheet-steel leg-plate, 
the correction force being a steel finger 
worked by a section of a toothed wheel 
and an endless screw. The shoe was 
bandaged to the inner side of the foot 
and the leg. This was modified by 





Fig. 249.— The Thomas 
club-foot wrench. 



Fig. 250.— The Thomas clubfoot wrench applied to a case of equinovarus. 

the writer, who placed the hinge at the outer side of 
the sole so that the inner margin of the foot was 
stretched instead of the outer margin being crowded 
together when the shoe was in use. Dr. Thomas L. 



314 

Stedman further improved the mechanism by substi- 
tuting a rack-and-pinion for the worm -and -screw action. 
These improvements are embodied in the shoe which 
Dr. Shaffer now uses and which is applied to the outer 
side of the leg and foot and is controlled by a ratchet- 
and-pinion action. 

When the lateral [deformity has been corrected, the 




Fig. 251.— Twisting the foot with the 
Thomas wrench. 



Fig. 252.— Twisting and dorsal flexing 
the foot with the Thomas wrench. 



anteroposterior deformity is attacked by a shoe con- 
sisting of three parts and two actions. A steel band 
passes around the back of the leg below the knee ; from 
this, two bars pass down, one on each lateral side of 
the leg to the malleoli, to join the heel-cup by a worm- 
and-screw mechanism. The foot is retained in the 



315 

heel-cup by a webbing-strap across the front of the 
ankle. The front half of the sole of the foot rests on a 
foot-plate which is joined to the bottom of the heel-cup 
by rack-and-pinion mechanism. A webbing-strap 
passes around the tip of the heel and passes down on 
each side of the foot to buckles on the bottom of the 
foot-plate. 

In using either shoe the surgeon, daily, or oftener, 
when possible, stretches the foot toward the normal 




Fig. 253.— The Thomas clubfoot brace. 



position up to the point of painful tolerance, holds it 
there for a short time, and relaxes the tension to the 
point of comfortable tolerance, where it is retained until 
again stretched. 

Thomas's method of correcting the deformity by fre- 
quently repeated wrenchings with retention in the 
intervals was foreshadowed by Thomas Sheldrake, of 
London, in 1798. He says : " The essential operation 



316 



to be performed in curing clubfoot is to produce such 
an extension of some of the ligaments, as, if it hap- 
pened by accident, would produce a sprain." Thomas's 
method has not been generally understood, and conse- 
quently has been neither appreciated nor practised by 
any except a few of Thomas's pupils. The method 
consists of intermittent stretching, or wrenching, by a 
wrench and retention in simple iron splint. It is the 
method par excellence for the treatment of young chil- 
dren among the poor, where for any reason tenotomy 
may not be performed. It is applicable to all degrees 




Fig. 254.— The first step in applying the Thomas clubfoot brace. 

of deformity in young children ; it gives as good results 
as can be obtained by any other method, or better ; it 
more rapidly corrects the deformity than any other 
nonoperative method ; and the cost is inconsiderable. 
But it is a cruel method, and one that cannot be em- 
ployed in many private cases. Many parents prefer a 
longer course of treatment, or the risks attendant upon 
an operation, to subjecting their child repeatedly to the 
painful wrenching. 

The wrench, Fig. 249, is made from a monkey-wrench 



317 

by sawing off the jaws of the wrench, boring a hole 
from the side through the fixed head-piece into which 
is set a strong pin and a like hole into the traveling 
head-piece into which is set a second pin. A slot must 
also be cut in the main stem of the wrench for the 
second pin to play through as the traveling head-piece 
moves up and down. A thin, slotted shield is placed 
at the base of the pins that the skin may not be 
pinched between the head-pieces as they approach each 
other. The pins should be straight and slightly bulb- 
ous at the ends to prevent their covers from slipping 
off. The pins may be snugly covered with thick, soft 
leather or with soft rubber. 

The wrench is applied to the foot, as shown in Fig. 
250 ; the foot is twisted and bent in the normal direc- 
tion, as shown in Figs. 251 and 252. The twisting 
and bending is done forcibly and quickly, and the foot 
immediately released. Holding the foot too long in 
the bite of the wrench may result in a pressure-sore. 
The keynote of this treatment is the extent to which 
the stretching or spraining is carried. The wrenching 
should be carried far enough to temporarily destroy 
the resiliency of the soft parts ; to such a degree that 
the foot is temporarily paralyzed and lies limp in the 
hand of the operator. It is then placed in the reten- 
tion-brace in its best possible position and held there 
by adhesive bandages. After two or three or more days, 
depending upon the severity of the deformity and the 
severity of the wrenching, the resiliency of the soft 
parts begins to return; the foot is then subjected again 
to the wrenching procedure. In this way the treat- 
ment is continued until the deformity is fully corrected 
and until it shows no tendency to return. After this 
the foot is retained in the corrected position until all 
the parts have adapted themselves to their new rela- 
tions ; or, as Thomas used to say, " until the slack had 



318 

been taken up " on the side of the convexity. This 
taking up of the slack is the second essential feature in 
this treatment. 

Surgeons have always known that corrected clubfeet 
were prone to relapse unless retained in the corrected 
position for a certain time, but the reason for the re- 
lapse, and a positive rule for diagnosticating a cure, 
have not heretofore been made known. It has been 
assumed that the stretched, torn or cut parts on the 




Fig. 255. — The second step in applying the Thomas clubfoot brace. 

side of the concavity have recontracted, but no worthy 
explanation has been advanced for this recontraction, 
and some have assumed that it was owing to some in- 
herent vice of these parts. The fact of the matter is, 
that the deformity returns from the same cause as a 
like deformity develops in noncongenital cases, namely, 
from a lack of muscular balance. 

In the noncongenital cases of equinovarus, the fault 
is a paralysis, and lies in the abductors and dorsal 



319 



flexors of the foot ; in the congenital cases the fault, to 
which the relapse is due, lies in these same muscles ; 
they are weak from disuse, and at a disadvantage from 
overlengthening. When the foot has been continuously 
held in a corrected or overcorrected position for a suffi- 
ciently prolonged period, structural shortening takes 
place in these elongated muscles, and in the ligamentous 
and other soft parts on the convexity of the deformity. 
When, then, the foot has been retained in the desired 
position so long that it cannot by manipulation be car- 
ried into the old deformed position any more readily 
than into the opposite defority, 
then, and not till then, can the 
treatment be discontinued, the pa- 
tient discharged cured, and the 
certainty of no relapse prognos- 
ticated. 

Tenotomy. — In so far as we know, 
the first section of a tendon for 
the correction of clubfoot was an 
open division of the tendo-Achillis 
by Lorenz at the suggestion of 
Thilenius, of Frankfort, in 1784. 
The first subcutaneous tenotomy 
is claimed to have been done by 
Mark Anthony Petit, in England, fig. 256.-ThI Thomas dub- 
in 1799. But it appears that the foot brace applied. 

operation was not repeated, for more than 30 years 
later William J. Little could find no one -in England to 
undertake the operation. On the continent, Michaelis 
operated in 1811, Sartorius in 1812, Delpech, of Mont- 
pellier, France, did subcutaneous tenotomy of the 
tendo-Achillis in 1816. But to Stromeyer, of Hanover, 
more than to any other, do we owe the development of 
the operation in 1831. To Stromeyer went Dr. William 
J. Little, of London, for the cure of his own foot when 




320 



he could find no one in England willing to do the new 
operation. Little introduced the operation into London^ 
in 1836. 

In America the first subcutaneous tenotomy for 
the cure of clubfoot was made by Dr. David L. Rodgers, 
of New York, in 1834, and the next by Dr. James H. 
Dickson, of North Carolina, in 1835. Dr. William Det-^ 
mold, of New York, operated in 1840, and did more to 
popularize the operation in this country than any other 
surgeon. He was followed by David Prince, who wrote 
in 1866, Louis Bauer, 1868, and Lewis A. Sayre, in 
1875. The comparatively recent 
date at which this operation was 
generally accepted may be realized 
by an editorial note in Dr. Town- 
send's translation of Velpeau's 
"Surgery," edited by Valentine 
Mott, in 1847. After reviewing the 
operation the editor says : " Not- 
withstanding the facts, the question 
of tenotomy still remains unde- 
cided." 

The operation as performed by 
most surgeons in England and 
America at the present day is prac- 
tically the same as that recom- 
mended by Stromeyer in 1831. It 
consists in correcting the lateral deformity (the varus) 
in so far as it is possible before attempting the division 
of the Achilles tendon. The tendon is then divided with 
a tenotome, a small knife with a short and narrow blade 
with a long shank. The tenotome is inserted flat be- 
neath the tendon, its edge is then turned towards the 
tendon which it is made to divide by a sawing motion. 
Care is taken not to separate the cut ends of the tendon 
until soft union has taken place at the end of from 




Fig. 257.— The tenotomes 
used by Mr, Robert 
Jones. 



321 

4 to 7 days. Then by manipulation and retention it is 
attempted to stretch the plastic material which unites 
the cut ends of the tendon until the desired position 
has been gained, the fear being that the cut ends of 
the tendon will not unite if they become too widely 
separated. As early, however, as 1838 Scoutetten ad- 
vised the immediate correction of the deformity after 
tenotomy, and this for many years has been practised 
by Say re, in New York, and R. W. Parker, in London. 
That distant separation of the cut ends of the tendon 
does not of itself cause nonunion we are sure, having 
obtained solid union where the separation, in a young 
woman, was If inches. 

Another fault in the old operation was the attempt 
at correction of the lateral deformity before the antero- 
posterior defect had been remedied. As pointed out in 
the remarks on the anatomy of clubfoot the body of 
the astragulus is often wedge shaped, with the apex of 
the wedge posteriorly, and there is, consequently, a short 
posterior ligament at the ankle-joint. Unless this liga- 
ment is cut, a somewhat difficult task, or torn before 
the tarsus itself is weakened by an operation, it will be 
found practically impossible to fully flex the foot; and 
unless full flexion well past the right angle be possible, 
relapse of the varus is sure to occur, for only by ad- 
ducting the foot at the tarsal joint is the patient able to 
bring the heel to the ground. 

The procedure, then, which we would advise, in the 
ordinary case of congenital equinovarus, is as follows : 
The foot is made clean; the patient is fully anesthet- 
ized, and turned on his face ; an assistant grasps the 
leg below the knee and dorsal-flexes the foot; the skin 
at the back of the ankle is drawn somewhat to one side 
and a puncture of the skin is made with the point of 
the tenotome at the side of the tendon about an inch 
above its insertion ; the puncture is carried across be- 



322 

tween the tendon and the skin ; the knife is withdrawn 
and replaced by a blunt-pointed tenotome; this is 
then turned with its edge to the tendon and the tendon 
cut, mainly by the pressure exerted on the back of the 
knife with the thumb of the other hand. Of course 
the knife can be entered below the tendon and the cut 
made towards the skin, but in doing this it is easy to 
puncture the tendon when intending to pass beneath 
it, in which case a second puncture will need to be 
made, and in the ankle of a fat bab}^ it is possible to 
mistake the fibula for the tendon and find that a sec- 
tion is not possible. In skilled hands the tendon may 
be cut with the sharp-pointed tenotome that is used to 
make the puncture, but it is hardly as safe as using the 
blunt instrument. As soon as the assistant feels the 
snap of the divided tendon he should instantly relax 
the flexion. When the cavity left by the incision has 
filled with blood the operator attempts full flexion of 
the foot. In a certain number of cases this will not be 
found possible, and the choice then is between a sec- 
tion or a forcible rupture of the posterior ligament of 
the ankle-joint. Section of this ligament is accom- 
plished by a spear-shaped tenotome passed through the 
middle of the tendo-Achillis, then turned half around 
and swept from side to side. We prefer, however, to 
rupture this ligament. The knee is flexed to a right 
angle and rests on the table, the leg being vertical, 
then with the hand grasping the foot the weight of the 
operator can be thrown upon it and the ligament read- 
ily ruptured. Unless full flexion at the ankle-joint be 
rendered possible before the anterior of the foot is sub- 
jected to operation it will be found very difficult of 
accomplishment. 

The next step is the division of all tight bands on the 
inner aspect of the foot in the neighborhood of the inner 
malleolus. The sharp pointed tenotome is inserted in 



323 

front of the inner malleolus at about the point where 
the anterior tibial tendon passes to the inner side of the 
foot and passed around under the malleolus closely 
hugging that bone ; the edge of the knife is then turned 
towards the shortened deltoid ligament which is divided 
as the knife is withdrawn. Through this same opening 
the tendon of the posterior tibial and that of the an- 
terior tibial and the astragalo-scaphoid capsule may be 
divided. The foot is then straightened and rotated 
outward and everted by forcible manipulation or the 
use of the Thomas wrench or the osteoclast. In a few 
instances the plantar fascia and the adductor of the 
great toe will require division through a puncture at the 
side of the sole in front of the lesser tuberosity of the 
OS calcis. There is only one rule as to what should be 
divided, namely, all tight bands that can be distin- 
guished by the touch ; after that every thing else that 
resists a full or even overcorrection of the deformity 
should be torn by the hand or the wrench or the osteo- 
clast. We usually seal the wounds with collodion and 
a pledget of cotton. In the tarsal region troublesome 
bleeding may be safely checked by a pressure com- 
press, but no pressure should be placed over the divided 
Achilles tendon. Pressure diminishes the quantity of 
plastic effusion and may be the cause of week union. 
A few layers of aseptic gauze are then placed over the 
wounds, the foot and leg enveloped in a wadding band- 
age and the whole put up in a plaster bandage from the 
toes to the knee, or above. The toes should be left 
exposed for an index of the circulation. The plaster is 
changed on the third or fourth day, when the wounds 
will usually be found healed. In infants the plaster- 
dressing, changed about every 2 weeks, is continued 
until the child begins to walk, when it is replaced by a 
retention brace. In older children the brace is applied 
as soon as the foot readily remains in the desired posi- 



324 

tion. The retention brace which we would recommend 
is either the Thomas clubfoot shoe, already described, or 
a brace consisting of a steel foot-plate with a flange turned 
up at the inner side, to which is attached a side-bar run- 
ning up the inner side of the leg to the garter line and 
thence halfway around the leg, the full circumference 
being completed by a strap and buckle. The side-bar 
and foot-plate are joined by a single strong rivet, set 
loosely so as to allow motion, which motion is limited 
to a right angle in extension by a stop set in the flange 
of the foot-plate. A narrow flange is usually turned up 
at the outer side of the heel, from which a strap of web- 
bing passes across the back above the tip of the heel, 
and the foot is held securely in place by another web- 
bing strap passing from underneath the heel around 
the outer side of the foot and across the instep to a 
buckle set on the inner flange of the foot-plate. This 
brace is worn inside the stocking to more securely 
grasp the foot. The brace shou'd be worn until the 
foot shows no tendency *to return to the deformed posi- 
tion, at least for 18 months, or even for a much longer 
period. 

Phelps' operation consists in making an open incision 
commencing in front of the inner malleolus and extend- 
ing one-third the distance across the sole of the foot, 
carried down to ihe neck of the astragalus, on its inner 
side. Through this wound the adductor pollicis, tibi- 
alis posticus, the plantar fascia, the flexor brevis, the 
long flexor tendons of the toe, and the deltoid ligament, 
all its branches if necessary, can be cut. This is done 
after subcutaneous tenotomy of the tendo-Achillis has 
been performed. Great force is then used by the 
noachine shown in Fig. 259, to rupture the deep liga- 
ments and supercorrect the foot. 

Any case that can be corrected by the hand, or by 
subcutaneous tenotomy, should not be subjected to 



325 

Phelps' operation ; and when the operation as described 
fails to easily supercorrect the foot, a linear osteotomy 
should be made through the neck of the astragalus. 
This failing, the removal of the cuboid and scaphoid is 
indicated. And, as a last resort, Pirogoff's amputation 
should be resorted to. 

The wounds of Phelps' operation are sutured, or not, 
as may be possible, and dressed without drainage with 
the aim to obtain blood-clot organization. The feet are 
dressed in supercorrected position in plaster-of-paris. 




Tit r r .• -^ ''"^/^ '"'' ^sure on me lett =shows line of incision in 
Phelps' operation The heavy hoes in the figure on the right show lines of 
incision m author's operation. 

Phelps first operated in 1879,>nd to him more than 
to any other is due the credit of leading the way to 
perfect results in inveterate cases of clubfoot. 

Ridlon's operation is> modification of Phelps' opera- 
tion, designed to avoid a tender 'scar of the sole of the 
foot. In Phelps' earlier operations, the incision was 
carried two-thirds across the sole of the foot ; at present 
it is carried but one-third that distance, and the objec- 



327 

tion to a tender scar holds less well than before the 
modified operation was devised. 

This operation consists of an incision commencing on 
the dorsum of the foot just in front of the inner malleolus 
at the point where the tendon of the extensor longus 
digitorum muscle crosses to the inner side of the foot ; 
from liere it is carried directly toward the sole, to meet, 
near its middle, a second incision made parallel with 
the sole from near the inner tuberosity of the os calcis 
to the middle of the first metatarsal bone or beyond. 
The plane of the first incision leads directly downward 
to the bones ; the plane of the second incision slopes 
upward and outward to reach the bones at their nearest 
border, thence it is carried underneath the bones, closely 
hugging them. As these incisions are made, an assist- 
ant constantly keeps the parts on the stretch in the 
direction of correction of the deformity and each part 
as it appears to resist the correcting influence is divided. 
When any considerable degree of equinus is present the 
incision passes beneath the anterior half of the inner 
malleolus, and in severe cases beneath the whole of it. 
The deltoid ligament, and the tendons of the tibialis 
anticus, extensor proprius hallucis, extensor longus 
digitorum, extensor brevis digitorum, tibialis posticus, 
flexor longus digitorum and flexor longus hallucis are 
readily reached. From the second incision the abductor 
hallucis, the plantar fascia, and any other resisting 
structures may be divided. By carrying the second 
incision in the plane directed it will almost always be 
possible to avoid dividing the internal plantar artery 
and the nerve. The division of all tight bands having 
been made, the foot is overcorrected by the hand, or 
by the wrench. As in Phelps' method, we believe it 
better to divide the tendo-Achillis and correct the 
equinus, rupturing, if necessary, the posterior ligament 
of the ankle-joint before commencing the operation for 



329 

-correcting the deformity of the anterior portion of the 
foot. The dressings are the same as in Phelps' opera- 
tion, namely, suturing in so far as it is possible without 
putting the parts at too great tension, and covering the 
wound with Lister protective and aseptic dressings, with 
the expectation that healing by blood- clot organization 
will take place. Over all is applied a plaster-of-paris 
dressing with the foot in the supercorrected position. 
In inveterate cases where the foot cannot be easily held 
in the supercorrected position, operations on the bones 
are indicated as pointed out under Phelps' operation, 
or Grattan's osteoclast may be used to crush the foot 
into the desired shape. Recently we have made use of 
this maneuver subsequent to subcutaneus tenotomy in 
preference to a bone-cutting operation. 

The principles first clearly emphasized we believe by 
Phelps, must never be lost sight of : First, correct all 
<;ases possible by hand; second, correct all possible by 
subcutaneous incision; third, of the remaining cases, 
divide by an open incision all resisting soft parts, and 
with the hand or some mechanical device supercorrect 
the deformity; fourth, when this cannot be readily 
done, do a linear osteotomy of the neck of the astragalus, 
followed, if necessary, by a cuneiform osteotomy of the 
OS calcis; if this is not sufficient, enucleate the astragalus, 
or remove any bone or portion of bone which blocks 
the way ; and if this is not sufficient, amputate. 

Linear osteotomy of the neck of the astragalus is 
demanded in inveterate cases in older children and 
adults where the inward twist of the head of the bone 
is so extreme that supercorrection cannot be made after 
free section of all the soft parts on the inner side of the 
foot. An incision is made on the outer surface of the 
dorsum of the foot over the neck of the astragalus and 
the bone is divided by an osteotome. The foot is placed 
in the desired position, the wound is closed without 



330 

drainage and dressed in the usual way. In a few cases 
linear osteotomy of the astragalus will not be found 
sufficient to permit of ovgrcorrection of the deformity. 
In such cases the incision is extended downward, the 
anterior portion of the outer surface of the os calcis is 
exposed, and a wedgeshaped piece removed from that 
bone just back of its anterior articular surface. 

In a certain number of cases, relapse takes place be- 
cause of the obliquity of this anterior articulating sur- 
face of the OS calcis, even when the deformity as a 
whole has been readily corrected either by tenotomy or 
stretching. In such cases cuneiform osteotomy of the 
OS calcis is indicated to pi event relapse. 

In a few cases the astragalus is partially displaced 
forward so that the posterior portion of the lower articu- 
lar surface of the tibia articulates with the os calcis, and 
the tibial articular surface of the astragalus is so 
changed in shape and direction that in all except very 
young infants restoration of full function in the direc^ 
tion of flexion is not possible except after the removal 
of that bone. When the head of the bone has been 
exposed by a curved incision over it, and separated 
from its attachments, it is grasped by a bone forceps 
and the rest of the ligamentous attachments can be 
most readily separated by the use of a grooved chisel. 
The wound should be dressed without drainage and 
with the foot in the supercorrected position. If the 
deformity cannot be sufficiently corrected by some one 
or all of the means indicated, so that a comely and 
useful foot results, amputation should be advised. 

Excision of a large wedge from the outer side of the 
foot without division of the soft parts internally, and 
without regard to what bones or portion of the bones 
are included in the wedge, is no longer generally per- 
formed. 



CONGENITAL DISLOCATION OF THE HIP. 

Congenital dislocation, or displacement, at the hip 
is not of very frequent occurrence, being less frequently- 
seen than congenital clubfoot. It was fairly well under- 
stood in France in the early part of the century, and 
some few cases were treated successfully. It was not 
recognized in England until the late Dr. Carnochan, of 
New York, pointed it out to the London surgeons in 
1844. Dr. Carnochan's book, published in New York 
in 1850, was the first work on the subject in English. 

The anatomic defect is found in the head and neck 
of the femur, in the acetabulum, and in the ligaments 
and muscles of the joint. In some young cases the 
changes are few and slight in character, except that the 
femoral head is displaced from the acetabulum. In 
other cases the changes are more marked. The head 
of the femur is often smaller than normal and imper- 
fectly rounded in its shape. The femoral neck is 
shorter, and at times smaller than normal, and is joined 
to the shaft at less than the usual obtuse angle. At 
times it is a right angle and at times less than a right 
angle. In some old cases the head and neck have been 
found to have nearly disappeared. The acetabulum is 
usually smaller than normal, though it may be rela- 
tively as large as the head of the femur. In a consid- 
erable number of cases it is more or less triangular in 
shape, and it is always shallow and partly filled with 
fat and fibrous tissue. The ligamentum teres is 
stretched and smaller, or ruptured, or has entirely dis- 
appeared. The cotyloid ring is contracted so that it 
may not be possible for the femoral head to enter 
through it into the acetabulum. The capsular liga- 
ment is stretched in proportion to the extent of the dis- 



332 

placement, it is more or less constricted, and may even 
be closed at the point of constriction in old cases. In a 
few old cases it has been found that the head of the 
bone had escaped from the capsule. There is structural 
shortening or lengthening in any of the muscles or all 
of the muscles that influence the movements at the 
hip. In some instances the shortening appears to be 
chiefly found in the short muscles, excepting the 
gluteal and the ilio-psoas, and in other instances it 
appears to be the long muscles that are chiefly at fault. 

The displacement is almost always upwards and 
backwards, or upwards and outwards on the dorsum 
of the ilium in the direction which the femur usually 
takes in traumatic dislocation. Indeed dislocation in 
no other direction was recognized, except in conjunction 
with monstrosities, until one of the authors (J. R.) re- 
ported an upward dislocation in 1889. Since then one 
other case has been reported by Dr. Ridlon, two by 
Dr. A. M. Phelps, and one by Dr. DeForest Willard. 
These were all dislocations upward and somewhat 
forward. 

The cause of congenital dislocation of the hip is not 
known. Carnochan believed that it was due to muscular 
retraction arising from irritation of the ganglionic cen- 
ters of the cord. The other causes to which it has been 
attributed are morbid retraction of a portion of the 
muscular tissues resulting from a defect in or absence 
of some portion of the nervous centers, arrested devel- 
opment, aberration of the nutritive forces, effusion into 
the joint cavity, relaxation of the muscular and liga- 
mentous structures, intrauterine pressure exerted upon 
the levers presented by the long bones, external vio- 
lence while in utero, traumatism occurring at birth, and 
heredity. Dupuytren, quoted by Carnochan, records 
the case of Marguerite Grandas, of Nantes, who had 
bilateral congenital dislocation. Her two maternal 



aunts had bilateral congenital dislocation; also one 
paternal aunt had unilateral dislocation, and another 
paternal aunt was the mother of a daughter who had 
unilateral congenital dislocation. Marguerite bore a 
daughter who had unilateral dislocation. This daughter 
married a healthy man whose father had bilateral dis- 
location, and bore four children ; two of these had 
unilateral dislocations. 

Personally we have seen few cases in which the defect 
was also found in the mother or had been handed down 
to the children. It is more often found in girls than 
in boys, more than 80% being girls, and in this it dif- 
fers from other hereditary defects which are more fre- 
quently found in boys. Injury at birth has been charged 
with the causation of a certain number of cases where 
the defect is unilateral, and where the bones, femoral 
head and acetabulum, have been found to nearly ap- 
proach the natural size and shape; but in these it must 
be remembered that an easy labor is quite as often re- 
corded as a difficult one. As above indicated, the dis- 
location may be of both hips or of only one. In our 
experience it is more frequently unilateral. 

The symptoms are not sufficiently pronounced to 
attract attention until the child begins to walk, or until 
it has walked for some months. In unilateral cases the 
symptom that then attracts attention is a limp ; in bi- 
lateral cases it is a waddling gait, a sway-back and a 
prominent abdomen. The limp, or the waddle which 
is simply a double limp, is due to the shortening and the 
insecurity of the femoral head for weight-bearing when 
displaced from its bony socket and resting on the but- 
tock muscles. The leg is shortened from ^ inch in 
infancy to If at 7 or 8 years of age and 2 J to 3 inches in 
adult life. There will be found an upward displace- 
ment of the greater trochanter equal to the amount of 
shortening. If a cord be drawn from the anterior 



334 



superior spine of the ilium across the hip to the tuber- 
osity of the ischium it will be found in the normal to 
pass across the tip of the greater trochanter ; in the 







Fig. 261.— Congenital dislocation of the right hip. 

congenitally dislocated hip it will pass below this point 
by as much as the limb is shortened. The limb is 



335 

smaller and flabbier than the sound Umb. The upper 
portion of the buttock is prominent ; the lower portion is 
flat; the hip is broadened laterally ; the perineum is 
broadened, noticeably in bilateral cases; the pelvis is 
tilted forwards, giving lumbar lordosis and a prominent 
abdomen, more marked in bilateral than in unilateral 
cases and increasing with age. All of these symptoms 
are more noticeable when the patients stand than when 
they lie. In cases of some standing a certain amount 
of flexion deformity is found by the Thomas flexion 
test. Movement at the hip in flexion, adduction and 
inward rotation are as free and often are freer than 
normal, while adduction, outward rotation and exten- 
sion are restricted to some extent. In a word, any 
motion that throws the femoral head against the dorsum 
of the ilium is restricted, and any motion that throws 
it away from the ilium is free. In standing, few patients 
show any rotary deformity of the limbs, although most 
writers note an outward rotation despite the fact that 
anatomically it appears to us that there must be an 
inward rotation unless there be twisting of the femoral 
neck. There is rarely any complaint of pain or disa- 
bility, except fatigue on long standing or walking, in 
tihe case of children ; on the other hand, in old cases 
there is often great disability, and patients at times take 
to crutches. 

The differential diagnosis from traumatic dislocation 
can not be made except by the history of the case. 
From pathologic dislocations they are distinguished 
by the history and by the freedom of motion in some 
direction; in pathologic dislocations the pathologic 
process which leads up to the dislocation restricts the 
motion at the joint to some extent in all directions. 
From infantile paralysis by the absence of flaccidity 
in the distal muscles. Doubless it is possible for infan- 
tile paralysis to affect the buttock muscles alone, leav- 



336 



ing the distal muscles untouched, but we are not aware 
that such a case has been reported. From congenital 
shortening of the whole limb by the fact that the shorten- 
ing is above the greater trochanter, while in congenital 
shortening the whole limb is uniformly arrested in it& 




Fig. 262.— Congenital dislocation of both hips (with lateral curvature of the 
spine) ; showing broadening of the hips and widening of the space between 
the thighs. 

growth. From fracture of the neck of the femur by 
the absence of a history of injury and by the presence 
of the head of the bone outside the acetabulum. 
Fracture of the neck of the femur is not uncommon in 
children, but we have not met with it in infancy. From 



337 

coxa vara by the presence of the head from the dorsum 
of the ilium, and by the history of the case that the 
child has always walked with a limp. We have 
not met with true coxa vara in children under five 
years of age. From hip disease there should be no 
difficulty in differentiating, for in hip disease motion at 
the hip is restricted to some extent in all directions. 

As to the prognosis : It does not effect life. With- 
out treatment these cases grow somewhat worse as time 
passes. Under treatment, some cases are cured, some 
cases are not benefited, and some cases are made worse. 

The treatment has been of three kinds : First, 
mechanical, without any attempt at manipulative re- 
duction of the dislocation ; second, traction by hand or 
by machine to stretch the contracted soft parts followed 
by manipulative reduction, as in traumatic disloca- 
tion ; and third, reduction in conjunction with a cutting 
operation. 

The mechanical treatment has aimed to pull the leg 
down, and to prevent its being pushed up again. To 
pull the leg down an apparatus has been used either by 
weights in bed or by the conventional traction hip- 
splint. It has been protected from being pushed up 
again in walking either by some form of perineal 
crutch, or by a corset or girdle, made to press downward 
upon the trochanters, and by restricting the lordosis 
rendering the femurs less secure through the iliopsoas 
muscles. No permanent results have been had from 
this form of mechanical treatment. 

Traction followed by manipulative reduction was 
first reported by Duval and Lafond in the case of a 
child of 9 years ; but the permanency of the result 
is not reported. In 1835, Humbert and Jacquier re- 
ported successful cases. The reports were doubted. It 
was believed that they converted dorsal into ischiatic 
dislocations. Parvez, of Lyons, reported successful 



338 

cases. His work was investigated by a committee of 
the Royal Academy of Medicine in 1836, and confirmed 
by their report in 1838. This plan of treatment, how- 
ever, fell into disuse despite a few favorable cases re- 
ported by Buckminster Brown, of Boston, William 




Fig. 263. — Congenital dislocation of both hips ; showing tilting forward of the 
pelvis and lordosis of the lumbar spine. 



Adams, of London, and Schede, of Hamburg, until 
recently it has received a new impetus from the work 
of Paci and of Lorenz. All cases are now subjected to 
this treatment before being condemned to a cutting 
-operation. 



339 

Manipulative reduction, as now performed, consists 
in pulling down the head of the bone and stretching 
the soft parts either by the hands of assistants or by 
mechanical means, the stretching process lasting several 
minutes. One of the authors (J. R.) is accustomed to 
fix the pelvis by passing a strong long towel between 




Fig. 264.— Congenital dislocation of both hips. 



the legs of the patient, bringing up one end along the 
groin and the other along the gluteo-femoral crease, 
and wrapping the ends around the hands of the opera- 
tor, who braces himself at the end of the table. Three 
or four assistants grasp the leg and a tug-of-war ensues. 



340 

When the head of the femur has been pulled down as 
far as seems necessary, or as far as is possible, the pull 
is let up. Then the operator, standing on the side 
of the patient away from the joint, flexes the thigh 
to a right angle, winds his arm around the thigh from 
without, under, inward, and outward across the groin. 
Holding thus, he adducts, flexes, and lifts the head of 
the femur towards the acetabulum, and rotates it from 
side to side while he holds the pelvis down with the 
other hand. If this maneuver is successful the head 
will be felt to slip into the acetabulum with a distinct 
click, which at times can be heard ; but oftentimes 
there is a false click, less distinct than that of the real 
replacement, which comes before it, and may delude 
the beginner. When the replacement has been effected 
the limb is carried into extreme abduction and held 
there while a plaster spica is applied from the knee to 
the scapula. The operator should always keep a hand 
upon the greater trochanter when carrying the thigh 
into abduction, for if the replacement has been a false 
one the head of the bone will be felt to slip upward 
again. If the replacement has been really accom- 
plished it will remain in place fairly securely. Many 
operators direct that in putting on the plaster-dressing 
the limb be held abducted and rotated inward, but we 
have held it abducted and rotated outward, believing 
it a more secure position. 

The first plaster dressing is kept on, if it remains 
firm, for about four weeks. The security of the head 
in the acetabulum may usually be readily determined 
by turning the patient on his face, placing the unop- 
erated thigh in a like position to the one operated 
upon, and using the thumb and first fingers of both 
hands as calipers to try the relations between the 
tuberosity of the ischium and the greater trochanter on 
both sides. 




Fig. 265.— Congenital dislocation of the right hip. 
The dislocation was upwards and slightly 
forwards. This case was reported by Dr. 
Eidlon, Nov. 16, 1888. In so far as we know 
this is the first case of upward dislocation 
reported. Since then one other case has been 
reported by Dr. Ridlon, two by Dr. A. M. 
Phelps, of New York, and one by Dr. De- 
Forest Willard, of Philadelphia. This child 
was 10 years old, and had had no treatment. 
The shortening when standing was three 
inches ; when lying it was two and a half 
inches. 



I 



342 



A certain number of cases relapse. We have generally 
had a relapse in cases over five years of age, but have 
had only one relapse in younger children ; that was a 




Fig. 266. — Same patient shown in Fig. 265. 

child of two years with unilateral dislocation whose 
mother had bilateral dislocation. We are accustomed 
to make a second or even a third replacement in case 



343 



of relapse, and if all relapse then there is nothing left to 
do but a cutting operation. We have been accus- 



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Fig. 267.— The same patient shown in Fig. 265, showing the 
shortening when standing. The lines mark the iliac 
crests and the greater trochanters. 



tomed to keep patients in bed from four to eight 
weeks before allowing them to walk, but we are 



344 

not sure that this is necessary. We have not made 
use of the high shoe on the opposite foot as has 
been recommended. We have continued the use of 
the plaster spica for 6 to 12 months. In some cases 
we have applied a light abduction splint after removal 
of the plaster. The splint consisted of a band about 
the chest, a band about the hips supplemented with 
perineal straps, and a band about the upper and an- 
other about the lower thigh, all bands connected by a 
bar at the side of the patient, hinged opposite the hip- 
joint for free anteroposterior motion and bent to the 
desired degree of abduction. The splint is more com- 
fortable than the plaster spica, but it is less secure. 

In no case have we had stiffness of the joint after 
the removal of the splint, or long after the removal of 
the plaster spica. We have not aimed, as Whitman 
has, to do as much harm as possible to the joint with 
the hope that adhesive inflammation would make the 
replacement more secure and with the desire to obtain 
a stiff and therefore a more stable joint. It appears to 
us a question whether a stiff hip is more to be desired 
than a freely movable one, though dislocated. In all 
cases there has been shortening of about a quarter of 
an inch. 

The first operative work was in the way of excision 
of the joint; this did not prove a success. Guerin, in 
cases where it was found impossible to retain the head, 
divided the shortened muscles subcutaneously and 
scarified to provoke effusion of organizing material. 
His work was investigated by a commission from 
the Council General of the Civil Hospitals of Paris in 
1843, and his ciires were confirmed. This method, 
however, fell into disuse. 

The popularization of the operative treatment for 
congenital dislocation of the hip is due to Hoffa, of 
Wiirzburg, who began this work about 10 years ago. 



345 



In 1891 we saw him operate, and the operation was 
substantially as follows : The patient was laid on his 




Fig. 268.— Showing the same patient shown in Figs. 265, 266 and 267, one year 
later after treatment in bed by traction. The lumbar lordosis has been 
overcome, as well as the flexion of the thigh, and the leg has been pulled 
down to the full length. A supporting walking splint is also shown. 

side, the thigh flexed to a right angle, an incision fol- 
lowing the line of the fibers of the gluteal muscle was 



346 

made over and down to the joint, the capsule opened, 
the head of the femur turned out of the wound, all 
muscular attachments to the femur were separated sub- 
periosteally down to the lesser trochanter, the capsule 
was then followed with the finger and the acetabulum 
located, this was then enlarged with a sharp spoon or 
a gouge until it was large enough to easily receive the 
head and deep enough to readily retain it, then the leg 
was straightened. Hoffa then claimed that unless the 
short muscles were separated from the femur the re- 
placed head would be thrown out of the acetabulum, 
when the leg was straightened from the flexed position. 

Lorenz, of Vienna, found that the obstacle to reten- 
tion of the replaced head was more often the long than 
the short muscles, and all these he divided, preliminary 
to opening the joint. He operated by an anterior in- 
stead of a posterior incision, and pared down the 
femoral head as well as enlarged the acetabulum. As 
a matter of fact it is sometimes one set of muscles and 
sometimes the other, and sometimes both that are at 
fault, and at other times it is not necessary to divide 
either, but better to use these shortened muscles as 
guys to securely retain the head in the acetabulum. 

Bradford, of Boston, and Sherman, of San Francisco, 
have shown that the relapse from manipulative replace- 
ment and the difficulty in operative replacement lies in 
the contracted cotyloid ring and the constricted capsule, 
and have been successful when they limited their opera- 
tive procedure to opening the joint, slitting up the cap- 
sule and cotyloid ring, replacing the head in the 
acetabulum with no folds of ligament or capsule between 
it and the cavity of the joint, and then sewing up the 
capsule around the neck of the femur, and fixing the 
limb in the abducted position as in manipulative re- 
placement. 

The Hofifa operation and all of its modifications that 



347 

call for the removal of bone either from the acetabulum 
or from the head of the femur are very serious opera- 
tions, the mortality is considerable, and ankylosed 
joints, or worse, frequently result. The Bradford-Sher- 
man operation, which removes no bone, promises to be 
a reasonably safe procedure when done by a cleanly 
surgeon. Infection of the wound in any of the cutting 
operations, however, is likely to result in caries and 
give a final result far worse than the original difficulty. 

Congenital Dislocation of the Shoulder. 

Congenital dislocation of the shoulder, properly so- 
called, is an exceedingly rare defect. Most of the cases 
that have in the past been called congenital dislocations 
at this joint have undoubtedly been traumatic disloca- 
tions occurring during the birth of the child. In true 
congenital dislocations the dislocation is said to be 
always subcoricoid or subacromial and the glenoid 
cavity is small and shallow, and the whole shoulder- 
joint is defective in its development. In the disloca- 
tions due to a traumatism inflicted at birth the struct- 
ures of the joint are all approximately normal. The 
joint-capsule may or may not be torn and the glenoid 
cavity may be intact or a small portion of the rim of 
the cavity may be broken off and carried away with 
the displaced head of the humerus. These dislocations, 
in so far as we know, are always subspinous and the 
arm takes the same position and presents much the 
same restrictions to motion that will be found in con- 
nection with this dislocation when occurring later 
in life. 

The arm is held close to the side, motion in all direc- 
tions is restricted, muscular atrophy is not present to 
any extent, the limb is rotated inward so that the de- 
pression between the shoulder and the chest is deepened 
into a groove and the shoulder looked at from the front 



348 



appears to be advanced ; looked at from the back, how- 
ever, it will readily be seen that the humerus is dis- 
placed backward. There is always a certain range of 
voluntary motion possible from the movement of the 
scapula. 

The differential diagnosis is from tubercular disease 
of the shoulder, which presents the same restriction to 
motion, but which shows muscular atrophy and often 







Fig. 269.— Congenital dislocation of right shoulder, probably due to injury at 
birth, showing characteristic position of adduction and inward rotation, and 
deepening of the crease between the shoulder and the chest. 



swelling from thickening of the capsule, tenderness and 
pain, and does not show the rotary deformity and the 
groove between the shoulder and the chest ; from in- 
fantile paralysis affecting the capsular muscles of the 
shoulder alone, and which presents the appearance of a 
downward displacement where there is no restriction 



349 

to passive motions while active movement is not possi- 
ble; and from traumatic palsies which are usually 
readily recognized from the history. 

The treatment is replacement of the dislocated head 
and retention for a period of many months. An attempt 
at replacement during anesthesia should always be 
made. In young cases it will often be successful ; in 
older cases it will often be a failure. Failure in at- 
tempted replacement and in retention after replacement 
should always be supplemented by a cutting operation. 
In truly congenital cases the cartilage of the head of 
the humerus should be erased ; in order that fibrous an- 




FiG. 270. 



-Rontgen picture of child in Fig. 269. Congenital dislocation of right 
shoulder. 



kylosis may result; in traumatic cases it may or may 
not be necessary to cut away some of the humeral head 
to accomplish the reduction, then the loose capsule 
should be gathered up and made firm, and the arm 
put up somewhat abducted and with the elbow carried 
far to the rear. 



Congenital Recurvation of the Knee. 

Congenital recurvation of the knee has been de- 
scribed as congenital dislocation, but in those cases 



350 



that have come under our observation there has been no 
true dislocation. The legs are bent forward on the 
thighs to 45° or more, they can not be bent in the 
normal direction beyond the straight line, or there- 
abouts, and the patellae are absent or at least rudimen- 
tary bones. The condition is often associated with 
other congenital defects such as clubfoot and spina 
bifida. 




Fig. 271. — A case of congenital recurvation of the knees. At birth the legs were 
flexed anteriorly on ihe thighs 45° and could be scarcely straightened. At 
the age of 21 months, when photographed, the knees could be flexed in the 
normal direction only as far as shown in the illustration. There was also 
present congenital knockknees, equinovarus, convergent squint, and spina 
bifida with incontinence of feces. 



The treatment is by passive bendings and retention 
in the best possible position. Good results are to be 
expected, the patellae usually developing as the normal 
range of motion and voluntary use is gained. 



351 



Congenital Dislocation of the Patella. 
Congenital displacement of the patella may be up- 
ward from an unduly long patellar ligament, or outward 
from a deficient outer condyle of the femur. The 
former is not as a rule a serious disability and will 
hardly prove a greater burden than the treatment. Out- 
ward displacement is a serious disability. It has been 
treated by various braces and trusses to retain the 
patella in its groove, but none are really satisfactory. A 
permanent cure can usually be readily effected by 
hammering the outer condyloid ridge with a rubber or 
a wooden mallet once a week until from periosteal irri- 
tion a ridge of sufficient height has been developed. 

Congenital Constriction Bands. 
Congenital constriction bands are rarely seen. We 
do not know what causes them, but they are met with 

in conjunction with other 
congenital deformities. 
They appear like narrow 
cicatricial bands closely 
hugging the bone and tend- 





FiG. 272. Fig. 273. 

Fig. 272 shows the outer aspect and Fig. 273 the inner aspect of a congenital con- 
striction band in a child V/^ years old. There was also present congenital 
equinovarus, webbed fingers, amputated fingers and constriction bands on 
one finger and two toes. 



352 



inous or ligamentous structures of an extremity. They 
may be readily removed by dissection. 



f 

% 

4 

h 

J 








m 


■ ■ ■■■■.-■ '.,;:%... ',..■. -.•'- 



Fig. 274.— Same case as shown ia Figs. 272 and 273 (same view as Fig 272) 
after operation. 



353 




Fig. 275 shows same case as shown in Figs. 272 and 273 (same view as Fig. 273) 
after operation. 



TNDEX. 



^bscess — 
psoas, 114 
tubercular in bone, 7 
treatment of, 104 et seq. 
Amputation in joint disease, 15 

Pirigoff s in club-foot, 325 
Ankle-clonus, 34 
Ankle-disease, 211 
diagnosis from tarsal disease, 

214 
pathology, 211 
symptoms, 211 
treatment — 
mechanical, 214 
operative, 214, 217 
Ankylosis, 11, 19, 124, 183, 187, 

217, 232 
Arthritis, tuberculous (see under 
names of various joints 
and diseases). 

"Rands, congenital constriction, 
-^ 351 

Harwell's dressing (see Dressing). 
Bed, Phelps' plaster b., 73 
Bone, tuberculosis of, 4-6 

(see, also, various diseases and 
joints). 
Bow-legs, 264 
treatment — 
mechanical, 265 et seq. 
operative, 265, 27u 
Brace — 
an tero -posterior leverage spi- 
nal b., 84, 95, 164 
Taylor spinal b., 84, 87 
Thomas— 
bowleg b., 265 
club-foot, 315, 317 
knock-knee, 266 
Bradford's frame (see Frame). 
Bridge, Ridlon's for plaster- 
jacket work, 63 
Brisement, in ankylosis of knee- 
joint, 210 

Qarpal disease, 248 

Chest, prominence of, 33 
Chicken-breast, 259 
treatment — 

mechanical, 259 

exercises, 260 



Club-foot, 292 
anatomy, 303 
diagnosis, 308 
etiology, 293 
prognosis, 308 
symptoms, 308 
treatment — 
by Thomas wrench, 315 
hand stretching, 309, 310 
osteotomy, 329 
Phelps' operation, 324 
Pirigoff' s operation 325 
Ridlon's operation, 325 
tenotomy, 319 
varieties, 292 
Collar, The Thomas, 95 
Congenital constriction bands 

(see Bands) 
Congenital dislocation of the hip 

(see Dislocation). 
Congenital dislocation of the pa- 
tella (see Dislocation). 
Congenital dislocation of the 
shoulder (see Disloca- 
tion). 
Congenital recurvation of the 

knee (see Recurvation). 
Contraction, psoas, 37 
Cot, canvas for recumbency, 68 
Coxalgia (see Hip Disease). 
Coxa Vara, 280, 283 
Crab splint. The, for ankle and 
tarsal disease (see Splint) . 
Cuirass — 
the Say re, 72 
the Thomas, 96 
the Thomas combined with 
hip splint. 179 
Curvatures (see Kyphos-is, Lor- 
dosis and Scoliosis). 
Cutter and bender for changing 
bed splints to caliper 
splints— 
Ridlon, 198 
Thomas, 197 



T)avis hip splint (see Splint). 
Deformity — 
rachitic, 249 

(see also Bow-leg, Knock-knee 
and Chicken-breast). 



356 



Diagnosis, differential (see under 

various diseases). 
Dislocation of hip — 
congenital, 142, 331 
anatomy of, 331 
ditferential diagnosis, 335 
etiology, 3S2 
prognosis, 337, 342 
symptoms, 333 
treatment — 
manipulative, 339 
mechanical, 337 
operative : 
• bloodless (see mechanical 
traction and manipula- 
tive treatment of), 
bloody, 344 

Bradford-Sherman, 346 
Guerin, 344 
Hoffa, 344, 346 
traction and manipulation, 
337 
spontaneous. 13S, 141 
traumatic, 143 
Dislocation of patella — 

congenital, 351 
Dislocation of shoulder, con- 
genital — 
differential diagnosis, 348 
symptoms. 347 
treatment, 349 
Displacement, pathologic, in 

shoulder disease, 230 
Dressing, Barwell's d. for club- 
foot, 312 

■pibow disease, 238 
■^ etiology, 238 » 
pathology, 238 
prognosis. 240 
symptoms, 238 
treatment- 
mechanical, 240 
operative, 242 
Erasion, 15 
(also see text on Operative 
Treatment of different 
diseases). 
Excision, ]5 

(also see text on Operative 
Treatment of different 
diseases). 

TTemur, fracture of (see Frac- 
-^ ture). 

Finger, tuberculosis of pha- 
langes of, 248 
Forcible straightening, 53, 61 
Fracture of neck of femur, 143 
Frame, Bradford's f. for recum- 
bency, 96 



Qenu valijum(see Knock-knee). 
Genu varum (see Bow-leg), 
Great Toe disease (see Toe). 

JJand, tuberculosis of metacar- 
pal bones. 248 
Hip disease. 47, 120 

complications, 138 

diagnosis, 134, 136, 141 

etiology, 120 

pathology. 121 

symptoms, 123 

treatment, 145 
Hip, disl'jcation of (see Disloca- 
tion). 
Hip-joint disease (see Hip-dis- 
ease) 
Hip-joint, spontaneous disloca- 
tion of (see Dislocation I. 
Hump -back (see Spondylitis). 
Hunch-back (see Spondylitis). 
Hysterical hip, 142 
Hysterical knee-joint, 194 
Hysterical spine, 45 

Jnfectious diseases in the eti- 
ology of spondylitis, 17 
laknee (see Knock-knee). 
Immobilization, 65 
Irritable spine. 45 

Joint disease — 

comphcations, 10 
etiology, 3, 4 

general principles relating to, 3 
order of involvement of struc- 
tures. 3-7 
passive motion in. 4 
pathology, 3-8 
prognosis, 11 
symptoms, 9 
treatment, 4, 11 
Joint disease, sacro-iliac (see 

Sacro-iliac). 
Jones' adjustable splint for wrist 

joint disease (see Splint) 
Judson hip-splint (see Splint). 
Jury-mast, 8-', 83 

J^ingsley's t. for estimating an- 
gle of flexion (see Table). 
Knee, congenital recurvatijn of 

(see Recurvation). 
Knee joint disease, 185 
differential diagnosis, 194 
etiology. 185 
prognosis, 187 
symptoms, 188 
treatment, 197 
mechanical, 198 
operative, 203 



357 



Knee-splints (see Splint). 
Knife. Ridlon s plaster k., 81 
Knock-knee— 

anatomy, 267 

treatment — 
mechanical. 267 
operative, 270 
Kyphos \ _ 
Kyposis I 

from spondylitis, 23, 31, 33 

from rickets, 264 

T ordosis, 36 

Lovett's table for computing 
abduction and adduction 
(see Table). 

IVTachine, Phelps', for club-foot, 
^^^ 326, 328 

Malignant disease, 47 
Metacarpal disease. 248 
Morbus coxae (see Hip disease). 

J^urse, Iron, Vo, 169, 171 

Qperation— 

Chiene's for knock-knee, 276 

Macewen's for knock-knee, 277 

Ogston's for knock-knee, 275 

Phelps' for club-foot, 324 

Pirigoflf's in club-foot, 325 

Reeves' for knock-knee, 276 

Ridlon's for club-foot, 325 
Orthopedic surgery, definition 

of, 2 
Osteoclasis, 270 
Osteoclast— 

Cabot, 272 

Colin, 274 

Grattan, 272 

Lorenz, 274 

Ridlon, 273 

Rizzoli, 271 

Robin, 274 

Thomas, 272 
Osteotomy — 

cuneiform, 274 

linear, 274 
Outknee, .80 

"Paraplegia in spondylitis, 24- 
■^ 26.29,31,33,40,53 

Patella, congenital dislocation 

of (see Dislocation). 
Phalangeal disease, 248 
Phelps' hip splint (see Splint). 
Phelps' machine for club-foot 

(see Machine). 
Phelps' operation for club-foot 

(see Operation). 



Pirigoff's operation in club-foot 

(see Operation). 
Plaster-bed, 73 
Plaster — 

in club-foot, 309 

in hip disease, 169 

in knee-joint disease, 199 

in knock-knee, 269 

in spondylitis, 62 
Plaster jacket, 74-84 
Pott's disease (see Spondylitis). 
Psoas abscess (see Abscess). 
Psoas contraction, 37 
Pyogenic membrane, 8 

J^achitic curvatures (see Ky- 
phosis and Scoliosis). 
Rachitic deformities (see De- 
formity ) . 
Rachitis (see Rickets). 
Recumbency, 66-74, 101 
Recurvations, congenital, of 
knee, 349 
symptoms, 350 
treatment, 350 
Rickets, 43, 249 
adolescent, 280 
anatomy, 280 
characteristics, 282 
diagnosis, 282-290 
treatment, 290 
infantile, 249 
etiology, 249 
pathology, 252 
prognosis, 257 
symptoms, 253 
treatment- 
dietetic and hygienic, 257 
medicinal, 258 
mechanical t. of the de- 
formities (see under each 
deformity;. 
Ridlon's— 
bridge (see Bridge), 
cutter and bender for chang- 
ing bed-splint to caliper- 
splint (see Cutter and. 
Bender 1. 
hip-splints (see Splints), 
operation lor club-foot (see 

Operation ) . 
plaster-knife (see Knife), 
sacral table (see Table). 
Rosary, rachitic, 254 

Qacro-iliac disease, 110 

differential diagnosis, 116 
etiology, 110 
pathology, 110 
prognosis, 111 
symptoms, 112 



358 



Sacro-iliac treatment, 116 
Sayre hip-splint (see Splint). 
Scarpa shoe (see Shoe). 
Scoliosis, 44, 46 
rachitic, 264 
Shaffer hip-splint (see Splint). 
Shoe— 
Scarpa, for club-foot, 308 
Taylor, for club-foot, 312 
Shoulder disease, 221 
traumatic — 
differential diagnosis, 234 
etiology, 221, 223 
symptoms and course, 223 
treatment, 237 
tuberculous — 
abscess in, 228 
anatomy of, 221 
complications, 228 
differential diagnosis, 234 
displacement, pathologic in, 

230 
etiology, 221 
pathology, 222 
symptoms, 227 
treatment, 234 
Shoulder-j oint — 
dislocation of (see Dislocation), 
displacement of, traumatic (see 
Displacement). 
Spinal caries (see Spondylitis). 
Sphnt— 
Blanchard hip- splint, 152 
crab-spUnt, the. 213, 215 
Davis hip-splint, 145 
Jones adjustable, for wrist- 
joint disease, 245 
Judson hip-splint, 146 
Phelps hip-splint, 151 
Ridlon fixation hip-splint, 177 
Ridlon long traction hip- 
splint, 150 
Sayre hip-splint— 
long, 148 
short, 145 
Shaffer hip-splint, 150 
Taylor hip-splint, 146 
Thomas knee-splint, 201 
Thomas hip-splint, 127, 129, 
153 
wrenches for (see Wrench). 

'pable— 

Kingsley's, for estimating 
angle of flexion, 133 



Table— Lovett's, for computing 
abduction and adduc- 
tion, 130 
Ridlon's sacral t., 275 
Tarsal disease, 211, 214 
differential diagnosis, 214 
symptoms, 214 
treatment, 
mechanical, 214 
operative, 217 
Test, Thomas flexion t., for hip 

disease, 136 
Thomas — 
bow-leg brace (see Brace), 
club-foot brace (see Brace), 
cutter and bender for changing 
bed-splint to caliper 
splint ( see Cutter and 
Bender), 
flexion test for hip disease (see 

Test) 
hip-splint (see Splint), 
knee-splint (see Splint), 
knock-knee brace (see Brace), 
wrench for club-foot (see 
Wrench). 
Toe disease, Great, 218 
etiology, 218 
symptoms, 218 
treatment — 
mechanical, 218 
operative, 219 
TractioD— 
head, 69, 71 
in hip disease, 157 
Tumor albus (see Knee-joint 
Disease). 

Tyhite swelling (see Knee-joint 

Disease). 
Whooping-cough in etiology of 

spondylitis, 17 
Wrench — 
Thomas' club-foot, 313 
for Thomas' high-spHnt, 181, 
182 
Wrist disease, 243 
etiology, 243 
prognosis, 243 
symptoms, 243 
treatment- 
mechanical, 244 
operative, 246 
Wry-neck (see Torticollis). 



JAN to i906 



